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  1. psnet.ahrq.gov/web-mm/production-pressures
    November 16, 2022 - Production Pressures Citation Text: Carayon P. Production Pressures. 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 Endnote tagged PubMedId …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49829/psn-pdf
    May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865656/psn-pdf
    April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous Combination April 24, 2024 Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination The Case A 26-ye…
  4. psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
    February 26, 2025 - In Conversation With… Ann L. Hendrich, RN, PhD December 1, 2011  Citation Text: In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Cita…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49455/psn-pdf
    July 01, 2004 - The Worst Headache July 1, 2004 Edlow JA. The Worst Headache. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/worst-headache The Case A 48-year-old woman with a history of migraine headaches and hypertension presented to her outpatient clinic with a 4-day history of headache. While shopping 4 days earlier, …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838855/psn-pdf
    October 27, 2022 - False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. October 27, 2022 Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
  7. psnet.ahrq.gov/perspective/conversation-suchi-saria-phd
    March 27, 2024 - In Conversation With… Suchi Saria, PhD July 1, 2019  Citation Text: In Conversation With… Suchi Saria, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …
  8. psnet.ahrq.gov/perspective/conversation-christine-cassel-md
    February 26, 2025 - In Conversation With… Christine Cassel, MD June 1, 2015  Citation Text: In Conversation With… Christine Cassel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33635/psn-pdf
    July 01, 2006 - In Conversation with...Allan Frankel, MD July 1, 2006 In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this kind of work. Dr. Allan …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49857/psn-pdf
    March 01, 2019 - Duplicate Insulin Order March 1, 2019 Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/duplicate-insulin-order The Case A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency department (ED) for complaints of letharg…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33702/psn-pdf
    November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH November 1, 2010 In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33875/psn-pdf
    March 01, 2019 - In Conversation With… Susan Haas, MD, MSc March 1, 2019 In Conversation With… Susan Haas, MD, MSc. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc Editor's note: Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs' work focused on health…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852808/psn-pdf
    August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication Breakdown. August 30, 2023 Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown Disclosure of Relevant Financial Relationship…
  14. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
    January 01, 2023 - Spotlight Spotlight Prolonged DKA in Pregnancy: A Case of Communication Breakdown Source and Credits • This presentation is based on the August 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Sarah Marshall, MD and Nina M. …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49573/psn-pdf
    January 01, 2009 - Dangerous Shift November 1, 2008 Patterson ES. Dangerous Shift. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dangerous-shift Case Objectives Review the evidence base on erroneous actions related to shift changes. Understand the limits of standardizing handoffs in preventing errors at shift change. Expla…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49760/psn-pdf
    May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33807/psn-pdf
    May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD May 1, 2016 In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd Editor's note: Dr. Drew, a nurse researcher, is the David Mortara Distinguished Professor of Physiological Nursing and…
  18. psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
    August 21, 2005 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism. Citation Text: Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation …
  19. psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
    July 23, 2024 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 31, 2023 Innovation Contact …
  20. psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
    August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. 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 XML E…

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