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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns
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Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary …
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psnet.ahrq.gov/node/33622/psn-pdf
November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP
November 1, 2005
In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
Editor's Note: Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare
I…
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psnet.ahrq.gov/node/50769/psn-pdf
February 15, 2017 - Cultural Competence and Patient Safety
December 27, 2019
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
Background
Culture can be defined as the “personal identification, language, thoughts, co…
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psnet.ahrq.gov/node/49664/psn-pdf
January 01, 2013 - Empty Handoff
September 1, 2012
Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/empty-handoff
The Case
A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a
leg wound. The patient's medical history included chronic…
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psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - A Statewide Collaborative to Support Vaginal Birth and
Reduce Unnecessary Cesarean Deliveries
July 8, 2022
https://psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-
cesarean-deliveries
Summary
Started in response to rising maternal morbidity and mortality rates in …
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psnet.ahrq.gov/node/33874/psn-pdf
February 01, 2019 - overall system improvement has become more apparent, health care delivery is
undergoing a transformation aimed
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psnet.ahrq.gov/issue/restorative-just-culture-exploration-enabling-conditions-successful-implementation
February 08, 2023 - Study
Restorative just culture: an exploration of the enabling conditions for successful implementation.
Citation Text:
Boskeljon-Horst L, Steinmetz V, Dekker SWA. Restorative just culture: an exploration of the enabling conditions for successful implementation. Healthcare (Basel). 2024;…
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH
September 28, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.In Conversation With... Freya Spielberg, MD, MPH. PSNet [internet]. Rockville (MD): Agen…
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psnet.ahrq.gov/issue/artificial-intelligence-and-surgical-decision-making
September 11, 2019 - Review
Classic
Artificial intelligence and surgical decision-making.
Citation Text:
Loftus TJ, Tighe PJ, Filiberto AC, et al. Artificial intelligence and surgical decision-making. JAMA Surg. 2019;155(2):148-158. doi:10.1001/jamasurg.2019.4917.
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…
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psnet.ahrq.gov/issue/understanding-swiss-cheese-model-and-its-application-patient-safety
May 25, 2022 - Commentary
Classic
Understanding the "Swiss cheese model" and its application to patient safety.
Citation Text:
Wiegmann DA, J. Wood L, N. Cohen T, et al. Understanding the "Swiss cheese model" and its application to patient safety. J Patient Saf. 2022;18(2):119…
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psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
September 28, 2022 - In Conversation With... Jack Westfall, MD, MPH
September 28, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Jack Westfall, MD, MPH. PSNet [internet]. 2022.In Conversation With... Jack Westfall, MD, MPH. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/issue/medication-errors-community-pharmacies-evaluation-standardized-safety-program
June 29, 2022 - Study
Medication errors in community pharmacies: evaluation of a standardized safety program.
Citation Text:
Ledlie S, Gomes T, Dolovich L, et al. Medication errors in community pharmacies: evaluation of a standardized safety program. Explor Res Clin Soc Pharm. 2023;9:100218. doi:10.1016…
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psnet.ahrq.gov/issue/systematic-review-frequency-and-quality-reporting-patient-and-public-involvement-patient
February 17, 2021 - Review
Systematic review on the frequency and quality of reporting patient and public involvement in patient safety research.
Citation Text:
Hammoud S, Alsabek L, Rogers L, et al. Systematic review on the frequency and quality of reporting patient and public involvement in patient safety…
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psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
July 10, 2024 - In Conversation With… Paul McGann, MD
March 1, 2016
Citation Text:
In Conversation With… Paul McGann, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
…
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psnet.ahrq.gov/issue/designing-safety-interventions-specific-contexts-results-literature-review
June 22, 2022 - Review
Designing safety interventions for specific contexts: results from a literature review.
Citation Text:
Karanikas N, Khan SR, Baker PRA, et al. Designing safety interventions for specific contexts: Results from a literature review. Safety Sci. 2022;156:105906. doi:10.1016/j.ssci.20…
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psnet.ahrq.gov/issue/positive-approaches-safety-learning-what-we-do-well
September 15, 2021 - Commentary
Positive approaches to safety: learning from what we do well.
Citation Text:
Plunkett A, Plunkett E. Positive approaches to safety: learning from what we do well. Paediatr Anaesth. 2022;32(11):1223-1229. doi:10.1111/pan.14509.
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Format:
DOI Google Sch…
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psnet.ahrq.gov/issue/crisis-management-during-anaesthesia-development-anaesthetic-crisis-management-manual
June 23, 2015 - Commentary
Crisis management during anaesthesia: the development of an anaesthetic crisis management manual.
Citation Text:
Runciman WB, Kluger MT, Morris RW, et al. Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. Qual Saf Health Care. …
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psnet.ahrq.gov/issue/artificial-intelligence-anesthetic-care-survey-physician-anesthesiologists
March 15, 2016 - Study
Artificial intelligence in anesthetic care: a survey of physician anesthesiologists.
Citation Text:
Estrada Alamo CE, Diatta F, Monsell SE, et al. Artificial intelligence in anesthetic care: a survey of physician anesthesiologists. Anesth Analg. 2024;138(5):938-950. doi:10.1213/ane…
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psnet.ahrq.gov/node/33804/psn-pdf
March 03, 2016 - In Conversation With… Paul McGann, MD
March 1, 2016
In Conversation With… Paul McGann, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
Editor's note: Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for
Medicare & Medicaid Services (CMS). He…
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psnet.ahrq.gov/node/33799/psn-pdf
January 01, 2015 - Burnout Among Health Professionals and Its Effect on
Patient Safety
January 1, 2015
Lyndon A. Burnout Among Health Professionals and Its Effect on Patient Safety. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
Annual Perspective 2015
Bur…