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  1. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. | PSNet

    psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
    November 25, 2020 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. Citation Text: Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…

  2. Hypoxic Gas Supply from Cross-Connected Pipelines | PSNet

    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. Copy Citation Format: Google S…

  3. Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. | PSNet

    psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
    August 14, 2024 - SPOTLIGHT CASE Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. Citation Text: Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

  4. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. | PSNet

    psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
    September 27, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. Citation Text: Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depa…

  5. In Conversation With... Remle P. Crowe, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
    May 16, 2022 - partnership and they're going to be following improvement science principles and doing these rapid tests

  6. Identifying Safety Events in the Prehospital Setting | PSNet

    psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
    May 16, 2022 - partnership and they're going to be following improvement science principles and doing these rapid tests

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60721/psn-pdf
    July 21, 2020 - Special Edition Perspective: Technology Responses to COVID-19 July 21, 2020 Marcin JP, Cohen NM, Lowery C, et al. Special Edition Perspective: Technology Responses to COVID-19. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19 Editor’s note: This …

  8. In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
    February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Essay View more articles from the same authors. Citation Text: Savitz LA, S…

  9. Learning Health Systems for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
    February 26, 2025 - Learning Health Systems for Patient Safety Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Savitz LA, Sousane Z, Mossburg SE. Learning …

  10. An Inadvertent Bolus of Norepinephrine. | PSNet

    psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
    December 04, 2016 - SPOTLIGHT CASE An Inadvertent Bolus of Norepinephrine. Citation Text: Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation F…

  11. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

    psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
    September 24, 2024 - You might go to get blood tests. You might get a CT scan.

  12. Patient Allergies and Electronic Health Records | PSNet

    psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
    August 21, 2005 - Patient Allergies and Electronic Health Records Citation Text: Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33735/psn-pdf
    August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and How to Fix It August 1, 2012 Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it Perspective At any point in time, …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49868/psn-pdf
    July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With Dementia July 2, 2019 Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia The Case An 86-year-old man with neurode…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49581/psn-pdf
    March 21, 2009 - Double Dosing, by the Rules March 21, 2009 Cohen H. Double Dosing, by the Rules. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/double-dosing-rules The Case A 65-year-old woman with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) was admitted to a medical unit during the night with wo…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867427/psn-pdf
    December 18, 2024 - The Ongoing Journey to Prevent Patient Falls December 18, 2024 Dykes PC, Sousane Z, Mossburg SE. The Ongoing Journey to Prevent Patient Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls Falls are not a new issue, especially among older adults. The Centers for D…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866621/psn-pdf
    August 28, 2024 - Application of Safety-II Principles August 28, 2024 Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/application-safety-ii-principles Traditional approaches to patient safety have often been reactive rather than proactive, seeki…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33778/psn-pdf
    March 01, 2015 - Diagnostic Errors January 1, 2014 Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/diagnostic-errors Annual Perspective 2014 Until very recently, diagnostic errors received relatively little attention in the field of patient safety, particularly when compared wi…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49563/psn-pdf
    May 01, 2008 - Is It Safe to Be Direct? May 1, 2008 Kulkarni NS, Williams M. Is It Safe to Be Direct? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/it-safe-be-direct The Case   A 92-year-old man with hypertension and heart failure (HF) was evaluated by his primary care physician (PCP) for progressive shortness of breat…

  20. Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx Spotlight When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Source and Credits • This presentation is based on the September 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psne…
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