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  1. 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 …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33704/psn-pdf
    December 01, 2010 - In Conversation with...Geri Amori, PhD December 1, 2010 In Conversation with..Geri Amori, PhD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd Editor's note: Geri Amori, PhD, is Vice President for the Education Center at The Risk Management and Patient Safety Institute, a…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49678/psn-pdf
    March 01, 2013 - A Weighty Mistake March 1, 2013 Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/weighty-mistake Case Objectives Understand factors associated with weight-based dosing medication errors in pediatric populations. Describe how adoption of computerized provider order entry (CPOE) s…

  4. Failure to Rescue | PSNet

    psnet.ahrq.gov/primer/failure-rescue
    September 15, 2024 - Failure to Rescue Citation Text: Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…

  5. Long-term Care and Patient Safety | PSNet

    psnet.ahrq.gov/primer/long-term-care-and-patient-safety
    February 24, 2022 - Long-term Care and Patient Safety Citation Text: Bakerjian D. Long-term Care and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

  6. Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax | PSNet

    psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
    December 14, 2022 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax Citation Text: Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …

  7. In Conversation with…William B. Weeks, MD, MBA | PSNet

    psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
    May 01, 2009 - an imaginative inquiry into how things could go wrong as we do them may be a very powerful safety tool

  8. Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up | PSNet

    psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
    September 27, 2023 - Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857059/psn-pdf
    November 29, 2023 - The Risks of a Malpositioned Gastrostomy Tube and Poor Communication November 29, 2023 Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication Disclosure of Relevant Financial …

  10. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations | PSNet

    psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
    October 27, 2022 - SPOTLIGHT CASE Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations Citation Text: Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. PSNet [internet]. Rockville (MD): Agency for He…

  11. In Conversation With… Timothy B. McDonald, MD, JD | PSNet

    psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
    February 26, 2025 - In Conversation With… Timothy B. McDonald, MD, JD April 1, 2019  Citation Text: In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy C…

  12. Patient Safety in the Ambulatory Care Setting | PSNet

    psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
    April 27, 2022 - Annual Perspective Patient Safety in the Ambulatory Care Setting August 5, 2022  View more articles from the same authors. Citation Text: Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. Rockville (MD): …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866343/psn-pdf
    December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency December 31, 2024 Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hyperte…

  14. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. | PSNet

    psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
    January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. Citation Text: Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866055/psn-pdf
    May 29, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle May 29, 2024 https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle Summary Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common catego…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837791/psn-pdf
    August 05, 2022 - Patient Safety in the Ambulatory Care Setting August 5, 2022 Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting Introduction There is no way to review the year 2021 in quality and …

  17. Out of Sight, Out of Mind: Out-of-Office Test Result Management | PSNet

    psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
    September 01, 2007 - SPOTLIGHT CASE Out of Sight, Out of Mind: Out-of-Office Test Result Management Citation Text: Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …

  18. Hidden Mystery | PSNet

    psnet.ahrq.gov/web-mm/hidden-mystery
    December 01, 2011 - SPOTLIGHT CASE Hidden Mystery Citation Text: Brunette DD. Hidden Mystery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  19. A "Reflexive" Diagnosis in Primary Care | PSNet

    psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
    April 01, 2008 - SPOTLIGHT CASE A "Reflexive" Diagnosis in Primary Care Citation Text: Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33680/psn-pdf
    March 22, 2009 - In Conversation with...Dean Schillinger, MD March 22, 2009 In Conversation with..Dean Schillinger, MD. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md Editor's note: Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco, Directo…
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