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  1. In Conversation With… John D. Birkmeyer, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
    January 31, 2024 - In Conversation With… John D. Birkmeyer, MD May 1, 2015  Citation Text: In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Fo…

  2. The Wet Read | PSNet

    psnet.ahrq.gov/web-mm/wet-read
    October 01, 2017 - SPOTLIGHT CASE The Wet Read Citation Text: Arenson RL. The Wet Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33828/psn-pdf
    March 01, 2017 - In Conversation With… Mary Dixon-Woods, DPhil March 1, 2017 In Conversation With… Mary Dixon-Woods, DPhil. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil Editor's note: Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University and Deputy …

  4. Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx Spotlight Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861760/psn-pdf
    January 31, 2024 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery January 31, 2024 Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…

  6. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure | PSNet

    psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
    March 01, 2005 - SPOTLIGHT CASE CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure Citation Text: Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…

  7. But See the Patient First | PSNet

    psnet.ahrq.gov/web-mm/see-patient-first
    September 27, 2023 - But See the Patient First Citation Text: Sinigayan VR. But See the Patient First. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

  8. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. | PSNet

    psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
    September 25, 2019 - SPOTLIGHT CASE Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. Citation Text: Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research …

  9. Chest Pain in a Rural Hospital | PSNet

    psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
    June 02, 2021 - SPOTLIGHT CASE Chest Pain in a Rural Hospital Citation Text: MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar Bi…

  10. Unintended Consequences of CPOE | PSNet

    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. Copy Citation Format: Google Scholar BibTeX EndNot…

  11. Do Not Disturb! | PSNet

    psnet.ahrq.gov/web-mm/do-not-disturb
    February 03, 2011 - SPOTLIGHT CASE Do Not Disturb! Citation Text: Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

  12. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records | PSNet

    psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
    May 26, 2021 - “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records Citation Text: MacDonald S. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…

  13. Postdischarge Follow-Up Phone Call | PSNet

    psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
    May 19, 2021 - SPOTLIGHT CASE Postdischarge Follow-Up Phone Call Citation Text: Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Schol…

  14. Isolated Clot, Real Error | PSNet

    psnet.ahrq.gov/web-mm/isolated-clot-real-error
    December 01, 2013 - SPOTLIGHT CASE Isolated Clot, Real Error Citation Text: Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  15. Triple Handoff | PSNet

    psnet.ahrq.gov/web-mm/triple-handoff
    March 01, 2004 - SPOTLIGHT CASE Triple Handoff Citation Text: Vidyarthi A. Triple Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  16. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy | PSNet

    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…

  17. Duty to Disclose Someone Else's Error? | PSNet

    psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
    June 01, 2004 - SPOTLIGHT CASE Duty to Disclose Someone Else's Error? Citation Text: Gallagher TH. Duty to Disclose Someone Else's Error?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Sch…

  18. Anchoring Bias With Critical Implications | PSNet

    psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
    June 15, 2022 - SPOTLIGHT CASE Anchoring Bias With Critical Implications Citation Text: Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google…

  19. Patient Safety: A Perspective from Office Practice | PSNet

    psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
    May 01, 2009 - improvement efforts and to ensure that people are getting evidence-based and effective care before they start

  20. Making Just Culture a Reality: One Organization's Approach | PSNet

    psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
    October 01, 2007 - This will take time, so start by removing the policies that are barriers to just culture and work incrementally
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