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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…
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psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
July 01, 2017 - In Conversation With… Michelle Mello, MPhil, JD, PhD
July 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Michelle Mello, MPhil, JD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Hum…
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psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md
June 01, 2018 - In Conversation With… Richard Hoppmann, MD
June 1, 2018
Also Read an Essay
Citation Text:
In Conversation With… Richard Hoppmann, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx
Spotlight
The Risks of a Malpositioned Gastrostomy Tube and
Poor Communication
Source and Credits
• This presentation is based on the November 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahr…
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP
July 1, 2012
Also Read an Essay
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 Service…
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psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
February 01, 2019 - In Conversation With… Susan E. Skochelak, MD, PhD
February 1, 2019
Also Read an Essay
Citation Text:
In Conversation With… Susan E. Skochelak, MD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
February 01, 2019 - Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula
Jed D. Gonzalo, MD, MSc, and Mamta K. Singh, MD, MSc | February 1, 2019
Also Read a Conversation
View more articles from the same authors.
Citati…
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psnet.ahrq.gov/node/33666/psn-pdf
October 01, 2008 - Methicillin-Resistant Staphylococcus aureus
April 1, 2008
Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
Perspective
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media …
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psnet.ahrq.gov/node/42426/psn-pdf
January 14, 2014 - Documenting quality improvement and patient safety
efforts: the quality portfolio. A statement from the
Academic Hospitalist Taskforce.
January 14, 2014
Taylor BB, Parekh V, Estrada CA, et al. Documenting quality improvement and patient safety efforts: the
quality portfolio. A statement from the academic hospitali…
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psnet.ahrq.gov/node/843234/psn-pdf
January 01, 2013 - clinicians through appropriate medications and doses.These methods, however, rely the
clinician to actively
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psnet.ahrq.gov/node/40875/psn-pdf
November 21, 2016 - Implementation of Condition Help: family teaching and
evaluation of family understanding.
November 21, 2016
Hueckel RM, Mericle JM, Frush K, et al. Implementation of condition help: family teaching and evaluation of
family understanding. J Nurs Care Qual. 2012;27(2):176-81. doi:10.1097/NCQ.0b013e318235bdec.
https:…
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psnet.ahrq.gov/node/41338/psn-pdf
September 24, 2016 - The association of workflow interruptions and hospital
doctors' workload: a prospective observational study.
September 24, 2016
Weigl M, Müller A, Vincent C, et al. The association of workflow interruptions and hospital doctors'
workload: a prospective observational study. BMJ Qual Saf. 2012;21(5):399-407. doi:10.1…
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psnet.ahrq.gov/node/39072/psn-pdf
November 04, 2009 - Variations in nursing care quality across hospitals.
November 4, 2009
Lucero RJ, Lake ET, Aiken LH. Variations in nursing care quality across hospitals. J Adv Nurs.
2009;65(11):2299-310. doi:10.1111/j.1365-2648.2009.05090.x.
https://psnet.ahrq.gov/issue/variations-nursing-care-quality-across-hospitals
This seconda…
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psnet.ahrq.gov/issue/medication-reconciliation-meets-its-match
May 01, 2017 - Newspaper/Magazine Article
Medication reconciliation meets its MATCH.
Citation Text:
Medication reconciliation meets its MATCH. Agency for Healthcare Research and Quality. Research Activities. May 2013:1, 3-4.
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psnet.ahrq.gov/node/47245/psn-pdf
July 11, 2018 - Moving patient safety into ambulatory settings and
beyond.
July 11, 2018
Ricciardi R, Shofer M. Moving Patient Safety Into Ambulatory Settings and Beyond. J Nurs Care Qual.
2018;33(3):195-199. doi:10.1097/NCQ.0000000000000329.
https://psnet.ahrq.gov/issue/moving-patient-safety-ambulatory-settings-and-beyond
In th…
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psnet.ahrq.gov/node/34061/psn-pdf
January 04, 2017 - Patient Safety Leadership WalkRounds.
January 4, 2017
Frankel A, Graydon-Baker E, Neppl C, et al. Patient Safety Leadership WalkRounds. Jt Comm J Qual Saf.
2003;29(1). doi:10.1016/s1549-3741(03)29003-1.
https://psnet.ahrq.gov/issue/patient-safety-leadership-walkrounds
This study shares the concept of an interventi…
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psnet.ahrq.gov/node/35975/psn-pdf
June 14, 2011 - A root cause analysis of clinical error: confronting the
disjunction between formal rules and situated clinical
activity.
June 14, 2011
Iedema RAM, Jorm C, Braithwaite J, et al. A root cause analysis of clinical error: confronting the disjunction
between formal rules and situated clinical activity. Soc Sci Med. 20…
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
February 01, 2013 - Perhaps they've just received a new diagnosis and may not feel that they can even participate actively
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psnet.ahrq.gov/node/39021/psn-pdf
October 14, 2009 - Medication safety in acute care in Australia: where are we
now? Part 2: a review of strategies and activities for
improving medication safety 2002-2008.
October 14, 2009
Semple SJ, Roughead EE. Medication safety in acute care in Australia: where are we now? Part 2: a
review of strategies and activities for improvi…
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psnet.ahrq.gov/node/41241/psn-pdf
June 15, 2012 - Using root cause analysis to reduce falls with injury in the
psychiatric unit.
June 15, 2012
Lee A, Mills PD, Watts B. Using root cause analysis to reduce falls with injury in the psychiatric unit. Gen
Hosp Psychiatry. 2012;34(3):304-11. doi:10.1016/j.genhosppsych.2011.12.007.
https://psnet.ahrq.gov/issue/using-ro…