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  1. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet

    psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - SPOTLIGHT CASE Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Citation Text: Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…

  2. In Conversation with… Edward Tenner, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
    June 01, 2011 - In Conversation with… Edward Tenner, PhD June 1, 2011  Also Read an Essay Citation Text: In Conversation with… Edward Tenner, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Cop…

  3. In Conversation With… David Blumenthal, MD, MPP | PSNet

    psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
    March 27, 2024 - In Conversation With… David Blumenthal, MD, MPP July 1, 2012  Citation Text: In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citati…

  4. In Conversation with… Michael Cohen, RPh, MS, ScD (hon) | PSNet

    psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
    April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD (hon) April 1, 2006  Also Read an Essay Citation Text: In Conversation with… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …

  5. The Impact of Communication on Medication Errors | PSNet

    psnet.ahrq.gov/web-mm/impact-communication-medication-errors
    August 01, 2009 - The Impact of Communication on Medication Errors Citation Text: Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867672/psn-pdf
    February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations February 26, 2025 Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. 2025. https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…

  7. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

    psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
    September 24, 2024 -   Safety as an uncompromisable value and zero harm as the goal are important and powerful alignment tools

  8. Patient Safety: A Perspective from Office Practice | PSNet

    psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
    May 01, 2009 - Patient Safety: A Perspective from Office Practice Richard J. Baron, MD | May 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Baron RJ. Patient Safety: A Perspective from Office Practice. PSNet [internet]. Rockville (MD…

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

    psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
    May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA May 1, 2009  Also Read an Essay Citation Text: In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

  10. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations | PSNet

    psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
    September 27, 2023 - SPOTLIGHT CASE Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations Citation Text: Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

  11. 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 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up Citation Text: Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…

  12. In Conversation with... Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace | PSNet

    psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
    October 31, 2023 - If we give healthcare workers the tools and techniques to deal with workplace violence, as we do with

  13. Addressing Workplace Violence and Creating a Safer Workplace | PSNet

    psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
    October 31, 2023 - If we give healthcare workers the tools and techniques to deal with workplace violence, as we do with

  14. In Conversation with…Robert M. Wachter, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
    October 01, 2008 - In Conversation with…Robert M. Wachter, MD October 1, 2008  Also Read an Essay Citation Text: In Conversation with…Robert M. Wachter, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845472/psn-pdf
    March 15, 2023 - In Conversation with... Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring March 15, 2023 In Conversation with.. Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-…

  16. In Conversation with...J. Bryan Sexton, PhD, MA | PSNet

    psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
    December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA December 1, 2006  Also Read an Essay Citation Text: In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006.In Conversation with...J. Bryan Sexton, PhD, MA. PSNet [internet]. Rockville (MD): Agency for…

  17. Identifying Adverse Events Not Present on Admission: Can We Do It? | PSNet

    psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
    October 01, 2008 - Identifying Adverse Events Not Present on Admission: Can We Do It? James M. Naessens, ScD | October 1, 2008  Also Read a Conversation View more articles from the same authors. Citation Text: Naessens JM. Identifying Adverse Events Not Present on Admission: Can W…

  18. Establishing a Safety Culture: Thinking Small | PSNet

    psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
    December 01, 2006 - Establishing a Safety Culture: Thinking Small Timothy J. Hoff, PhD | December 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. Rockville (MD): Age…

  19. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
    January 01, 2024 - Spotlight Spotlight Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis 1 Source and Credits This presentation is based on the December 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Comment…

  20. Workarounds and Resiliency on the Front Lines of Health Care | PSNet

    psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
    August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care Anita L. Tucker, DBA, MS | August 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSN…
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