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psnet.ahrq.gov/node/33787/psn-pdf
January 01, 2018 - In Conversation With… Maureen Bisognano
June 1, 2015
In Conversation With… Maureen Bisognano. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-maureen-bisognano
Editor's note: Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement
(IHI). We spoke with her about I…
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psnet.ahrq.gov/node/49737/psn-pdf
June 01, 2015 - Unseen Perils of Urinary Catheters
June 1, 2015
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
The Case
A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
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psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
February 26, 2025 - In Conversation With… Eric J. Topol, MD
September 1, 2015
Citation Text:
In Conversation With… Eric J. Topol, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
March 17, 2025 - Breadcrumb
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Created By: Lorri Zipperer, Cybraria…
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psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - SPOTLIGHT CASE
The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy
Citation Text:
Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - In Conversation With… Tejal K. Gandhi, MD, MPH
April 1, 2014
Citation Text:
In Conversation With… Tejal K. Gandhi, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - SPOTLIGHT CASE
Crushing Chest Pain: A Missed Opportunity
Citation Text:
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
December 08, 2021 - SPOTLIGHT CASE
When Patients and Providers Speak Different Languages
Citation Text:
Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - SPOTLIGHT CASE
Unintended Consequences of CPOE
Citation Text:
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Google Scholar BibTeX EndNot…
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis.
Citation Text:
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Google Scholar Bi…
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/50754/psn-pdf
December 18, 2019 - "Do You Want Everything Done?": Clarifying Code Status
December 18, 2019
Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
Disclosure of Relevant Financial Relationships: As a p…
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psnet.ahrq.gov/information/Faq
November 01, 2019 - Case submitters should expect a response within 10–12 weeks.
Can I submit a commentary?
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - three-by-five card, I wouldn’t know what their throat looked like, or whether they had a fever, or what their response
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psnet.ahrq.gov/node/33857/psn-pdf
July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP
July 1, 2012
In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
Editor's note: Dr. Blumenthal is President of the Commonwealth Fund and served as the National
Coordinator …
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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - SPOTLIGHT CASE
Hidden Heparins: HIT Happens
Citation Text:
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed
Diagnoses of Cancer
July 31, 2023
https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
Summary
Concern over patient safety issues associated with inadequate tracking of test results has grown over the
last decade, a…
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psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
November 01, 2016 - SPOTLIGHT CASE
Dying in the Hospital With Advanced Dementia
Citation Text:
Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - In Conversation With… Gordon Schiff, MD
July 1, 2018
Citation Text:
In Conversation With… Gordon Schiff, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
July 10, 2024 - In Conversation With… Paul McGann, MD
March 1, 2016
Citation Text:
In Conversation With… Paul McGann, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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