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psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric
Patients at Risk of Physiologic Instability
December 23, 2020
Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at
Risk of Physiologic Instability. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm…
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - Hard to Swallow
October 1, 2004
Driver J. Hard to Swallow. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/hard-swallow
The Case
An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic
attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
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psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-flags-dont-miss-diagnoses-and-diagnostic-pitfalls
February 17, 2021 - Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls
Citation Text:
Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departme…
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psnet.ahrq.gov/training-catalog
June 01, 2025 - Training Catalog
The AHRQ PSNet Training Catalog is an easy to use resource for healthcare professionals across all settings of care and specialties looking for education opportunities to further their knowledge of patient safety practices and principles. Some training opportunities are available as in-person meeting…
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psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
September 01, 2005 - Benefits vs. Risks of Intraosseous Vascular Access
Citation Text:
Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. 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/node/49407/psn-pdf
July 01, 2003 - Bleeding Risk
July 1, 2003
Crowther MA. Bleeding Risk. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/bleeding-risk
The Case
A frail 78-year-old woman fell at home and fractured her left hip. Her past medical history included atrial
fibrillation, hypertension, coronary artery disease, and stroke. The surgi…
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psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
May 01, 2012 - Situational Awareness and Patient Safety
Citation Text:
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
April 01, 2009 - Accreditation and Regulation: Can They Help Improve Patient Safety?
Rebecca N. Warburton, PhD | April 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Warburton RN. Accreditation and Regulation: Can They Help Improve Pat…
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psnet.ahrq.gov/issue/using-harm-based-weights-ahrq-patient-safety-selected-indicators-composite-psi-90-does-it
March 15, 2016 - Study
Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals?
Citation Text:
Chen Q, Rosen AK, Borzecki A, et al. Using Harm-Bas…
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psnet.ahrq.gov/innovation/esimpler-dynamic-electronic-health-record-integrated-checklist-clinical-decision-support
June 16, 2021 - EMERGING INNOVATIONS
eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.
Citation Text:
Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support duri…
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psnet.ahrq.gov/node/867805/psn-pdf
February 26, 2025 - In Conversation with David W. Bates about Are We Safer
Today?
February 26, 2025
Bates DW, Lee M, Mossburg SE. In Conversation with David W. Bates about Are We Safer Today? PSNet
[internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
Editor’s note: David W. Bates, …
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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
September 18, 2024 - SPOTLIGHT CASE
Diagnostic Delay in the Emergency Department
Citation Text:
Marshall K, Singh H. Diagnostic Delay in the Emergency Department. 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/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
October 30, 2024 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department
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psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Intraosseous Line Extravasation in a
Pediatric Trauma Patient
Source and Credits
• This presentation is based on the April 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: David Barnes, MD and Joseph Yoon, MD
o…
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psnet.ahrq.gov/node/49566/psn-pdf
July 01, 2008 - What Was in Those Platelets?
July 1, 2008
Yomtovian R. What Was in Those Platelets? . PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/what-was-those-platelets
The Case
A 47-year-old woman was admitted to the hospital for complex spinal surgery. The surgery went well
without complications, and postoperativel…
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - SPOTLIGHT CASE
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
Citation Text:
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
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psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - Misconnection Leading to Arterial Thrombosis
Citation Text:
Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - Hypoxic Gas Supply from Cross-Connected Pipelines
Citation Text:
Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - SPOTLIGHT CASE
A Laceration that Needed a Proper Exam, Not an X-Ray
Citation Text:
Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray.. 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/web-mm/bleeding-risk
November 01, 2003 - Bleeding Risk
Citation Text:
Crowther MA. Bleeding Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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