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psnet.ahrq.gov/issue/improvement-pennsylvania-healthcare-consumers-awareness-patient-safety
March 30, 2016 - Newspaper/Magazine Article
Improvement of Pennsylvania healthcare consumers' awareness of patient safety.
Citation Text:
Improvement of Pennsylvania healthcare consumers' awareness of patient safety. Munn J. PA-PSRS Patient Saf Advis. March 2014;11:23-29.
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psnet.ahrq.gov/issue/quality-improvement-neurosurgery
May 24, 2017 - Special or Theme Issue
Quality Improvement in Neurosurgery.
Citation Text:
Quality Improvement in Neurosurgery. Rolston JD, Han SJ, Parsa AT, eds. Neurosurg Clin N Am. 2015;26(2):143-322.
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psnet.ahrq.gov/issue/take-charge-5-steps-safer-healthcare
May 03, 2023 - Multi-use Website
Take Charge: 5 Steps to Safer Healthcare.
Citation Text:
Take Charge: 5 Steps to Safer Healthcare. Wantagh, NY; Pulse Center for Patient Safety, Education & Advocacy.
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psnet.ahrq.gov/issue/us-drug-shortages-threatening-those-whose-lives-depend-crucial-remedies
May 17, 2006 - Newspaper/Magazine Article
US drug shortages threatening those whose lives depend on crucial remedies.
Citation Text:
US drug shortages threatening those whose lives depend on crucial remedies. Stein R. Washington Post. May 2, 2011:A10.
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psnet.ahrq.gov/issue/patients-put-risk-nhs-computer-fault
November 04, 2012 - Newspaper/Magazine Article
Patients put at risk by NHS computer fault.
Citation Text:
Patients put at risk by NHS computer fault. Gray R.
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psnet.ahrq.gov/issue/medical-mistakes-no-longer-billable-bold-steps-taken-state-reduce-hospital-errors
August 06, 2008 - Newspaper/Magazine Article
Medical mistakes no longer billable: bold steps taken by state to reduce hospital errors.
Citation Text:
Medical mistakes no longer billable: bold steps taken by state to reduce hospital errors. Smith S.
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psnet.ahrq.gov/issue/thirty-safe-practices-better-health-care
December 24, 2008 - Government Resource
Thirty Safe Practices for Better Health Care.
Citation Text:
Thirty Safe Practices for Better Health Care. AHRQ; Agency for Healthcare Research and Quality; NQF; National Quality Forum
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psnet.ahrq.gov/issue/annual-communication-apology-and-resolution-care-forum
May 03, 2023 - United States Meeting/Conference
Annual Communication, Apology, and Resolution (CARe) Forum.
Citation Text:
Annual Communication, Apology, and Resolution (CARe) Forum. Betsy Lehman Center for Patient Safety.
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psnet.ahrq.gov/issue/forgive-and-remember-managing-medical-failure-2nd-ed
March 27, 2005 - Book/Report
Classic
Forgive and Remember: Managing Medical Failure. 2nd ed.
Citation Text:
Forgive and Remember: Managing Medical Failure. 2nd ed. Bosk CL.Chicago, IL: University of Chicago Press; 2003. ISBN: 9780226066783.
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psnet.ahrq.gov/issue/stem-tide-addressing-opioid-epidemic
April 15, 2021 - Toolkit
Stem the Tide: Addressing the Opioid Epidemic.
Citation Text:
Stem the Tide: Addressing the Opioid Epidemic. Chicago, IL: American Hospital Association; 2017.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.110_slideshow.ppt
December 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case December 2005
Low on the Totem Pole
Source and Credits
This presentation is based on the Dec. 2005
Spotlight Case in Surgery/Anesthesia
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Robert Wachter, MD, …
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psnet.ahrq.gov/curated-library/opioid-stewardship
December 15, 2024 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Opioid Stewardship
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Created By: AHRQ
Date Created: January 24, 2025
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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - .
– Obesity, adhesive disease from prior surgeries (especially of the foregut), and atypical location
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psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
February 01, 2012 - In Conversation With… Lawrence Smith, MD
February 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… Lawrence Smith, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care
Source and Credits
• This presentation is based on the 2020 AHRQ WebM&M Spotlight
Case
○ See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD
○ Editor…
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Delayed Diagnosis of Mesenteric Ischemia
Source and Credits
• This presentation is based on the August 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc
o AHRQ WebM&M…
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psnet.ahrq.gov/node/862983/psn-pdf
February 28, 2024 - Airway Obstruction during Anterior Cervical Spine
Surgery
February 28, 2024
Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
The Case
A 47-year-old obese man (body weight 13…
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy
Citation Text:
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
February 26, 2025 - Wrong site surgeries are a pretty good example of this—they happen to every big institution a few times
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psnet.ahrq.gov/node/846915/psn-pdf
March 29, 2023 - The severity of the burns required four skin grafts and nearly two dozen laser surgeries.