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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Citation Text:
Savitz LA, S…
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
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View more articles from the same authors.
Citation Text:
Savitz LA, Sousane Z, Mossburg SE. Learning …
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psnet.ahrq.gov/perspective/conversation-connor-wesley-rn-bsn-patient-safety-concerns-and-lgbtq-population
February 01, 2023 - In Conversation with... Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population
February 1, 2023
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Citation Text:
In Conversation with.. Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population. PSNet [inte…
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psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
August 01, 2014 - Beyond the Hospital: the New Frontier of Patient Safety
Margaret Plews-Ogan, MD, MS | August 22, 2014
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Citation Text:
Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet …
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psnet.ahrq.gov/node/867427/psn-pdf
December 18, 2024 - The Ongoing Journey to Prevent Patient Falls
December 18, 2024
Dykes PC, Sousane Z, Mossburg SE. The Ongoing Journey to Prevent Patient Falls. PSNet [internet].
2024.
https://psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
Falls are not a new issue, especially among older adults. The Centers for D…
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psnet.ahrq.gov/node/50931/psn-pdf
February 26, 2020 - Timely diagnosis of esophageal perforation
February 26, 2020
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
The Case
A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…
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psnet.ahrq.gov/node/866847/psn-pdf
September 25, 2024 - In Conversation with Carole Stockmeier about Zero Harm:
Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 25, 2024
Stockmeier CA, Mossburg S, Lee M. In Conversation with Carole Stockmeier about Zero Harm: Striving to
Reduce Preventable Harms – Point, Counterpoint, and Are…
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psnet.ahrq.gov/node/33644/psn-pdf
December 01, 2006 - Establishing a Safety Culture: Thinking Small
December 1, 2006
Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
Perspective
Safety cultures are the holy grail in any risky industry. Like all holy grails, th…
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psnet.ahrq.gov/node/49619/psn-pdf
February 01, 2011 - Paradoxical Pulse
February 1, 2011
Roy CL. Paradoxical Pulse. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/paradoxical-pulse
The Case
An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful
pacemaker placement as an outpatient. The patient was restarted on …
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psnet.ahrq.gov/web-mm/lap-burn
March 01, 2018 - Lap Burn
Citation Text:
Ball K. Lap Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/node/33827/psn-pdf
February 01, 2017 - New Insights About Team Training From a Decade of
TeamSTEPPS
February 1, 2017
Baker DP, King HB, Battles J. New Insights About Team Training From a Decade of TeamSTEPPS. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
Perspective
Ten years ago, the Ag…
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psnet.ahrq.gov/node/33848/psn-pdf
December 01, 2017 - The Evolution of Patient Safety in Surgery
December 1, 2017
Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
Perspective
In 1979, 20 years before the Institute of Medicine's To Err Is Human report (1) catalyzed the cr…
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psnet.ahrq.gov/node/49656/psn-pdf
June 01, 2012 - Comanagement: Who's in Charge?
June 1, 2012
Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/comanagement-whos-charge
The Case
A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left
hip fracture to the orthopedic surg…
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psnet.ahrq.gov/node/49514/psn-pdf
July 01, 2006 - One ACE Too Many
July 1, 2006
Juurlink DN. One ACE Too Many. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/one-ace-too-many
The Case
A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure
presented to the emergency department (ED) with chest pain. An acut…
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psnet.ahrq.gov/node/49420/psn-pdf
October 01, 2003 - To LP or Not LP
October 1, 2003
Landrigan CP. To LP or Not LP. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/lp-or-not-lp
The Case
A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with
fever and irritability without an obvious source. He was referred to …
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psnet.ahrq.gov/node/49842/psn-pdf
September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric
Emergency Equipment
September 1, 2018
Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet
[internet]. 2018.
https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
The Case
As part of…
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psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - Central, not Epidural
September 1, 2011
Simmons D. Central, not Epidural. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/central-not-epidural
The Case
A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively,
he was awake, alert, and oriented to time, place,…
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psnet.ahrq.gov/node/33868/psn-pdf
October 01, 2018 - Safety in the Retail Pharmacy
October 1, 2018
Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-retail-pharmacy
Perspective
There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each
year.(1) Many patients interact w…
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psnet.ahrq.gov/node/60548/psn-pdf
May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD
May 28, 2020
In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at
the Food…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - PowerPoint Presentation
Spotlight Case
Multifactorial Medication Mishap
1
This presentation is based on the February 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Annie Yang, PharmD, BCPS
NYU Langone Medical Center
Editor, AHRQ WebM&M: Robe…