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psnet.ahrq.gov/web-mm/breakage-picc-line
June 21, 2023 - SPOTLIGHT CASE
Breakage of a PICC Line
Citation Text:
Dimov V. Breakage of a PICC Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs015409-overhage-final-report-2009.pdf
January 01, 2009 - Title Page
Grant Final Report
Grant ID: R01 HS 015409
Value of Health Information Exchange in
Ambulatory Care
Inclusive dates: 09/01/04 - 09/31/09
Principal Investigator:
J. Marc Overhage, MD, PhD; Director, Regenstrief Institute Medical Informatics; Regenstrief
Professor of Medicine,…
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - SPOTLIGHT CASE
Double Trouble
Citation Text:
Gurwitz JH. Double Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
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psnet.ahrq.gov/node/33809/psn-pdf
June 01, 2016 - In Conversation With… Gregg S. Meyer, MD, MSc
June 1, 2016
In Conversation With… Gregg S. Meyer, MD, MSc. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
Editor's note: Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based
system tha…
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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - SPOTLIGHT CASE
Thin Air
Citation Text:
Gaba DM. Thin Air. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs015377-schadow-final-report-2008.pdf
January 01, 2008 - Value of New Drug Knowledge for e-Prescribing
Grant Final Report
Grant ID: R01HS15377
Value of New Drug Knowledge for e-Prescribing
Inclusive Dates: 09/8/04 - 08/31/08
Principal Investigator:
Gunther Schadow
Team Members:
CJ Fleck
Mahesh Nalkande
Akshay Sangawar
Chris Rosenth…
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meps.ahrq.gov/data_files/publications/st440/stat440.shtml
June 01, 2014 - STATISTICAL BRIEF #440:
Expenditures for Treatment of Mental Health Disorders among Children, Ages 5-17, 2009-2011: Estimates for the U.S. Civilian Noninstitutionalized Population
Skip to main content
An official web…
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meps.ahrq.gov/data_files/publications/st393/stat393.shtml
November 01, 2012 - STATISTICAL BRIEF #393: Expenditures for Heart Disease among Adults Age 18 and Older: Estimates for the U.S. Civilian Noninstitutionalized Population, 2009
Skip to main content
An official website of the Department of He…
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psnet.ahrq.gov/node/50928/psn-pdf
February 21, 2020 - Updates in the Role of Health IT in Patient Safety
February 21, 2020
Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
Background
Health information technology (HIT) has the potential…
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psnet.ahrq.gov/node/846563/psn-pdf
March 21, 2023 - Impact of System Failures on Healthcare Workers
March 21, 2023
Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
Introduction
The March 2022 conviction of RaDonda Vaught, a former nu…
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www.ahrq.gov/sites/default/files/2024-07/seid-sobo-report.pdf
January 01, 2024 - Final Progress Report: Managing the Health Needs of Vulnerable Children
Title of Project: Managing The Health Needs of Vulnerable Children
Principal Investigator and Team Members: Michael Seid, PhD, Elisa J. Sobo, PhD
Organization: Children’s Hospital Research Center
Inclusive Dates of Project: 9/30/2001 - 9/29/…
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psnet.ahrq.gov/node/33736/psn-pdf
September 01, 2012 - In Conversation With… Jack Needleman, PhD
September 1, 2012
In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management
at UCLA School of P…
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous
Combination
April 24, 2024
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous
Combination. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
The Case
A 26-ye…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
March 12, 2008 - Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes
Evaluation of Medications Removed from Automated
Dispensing Machines Using the Override Function
Leading to Multiple System Changes
Karla Miller, PharmD; Manisha Shah, MBA, RT; Lau…
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psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
September 01, 2017 - Missed Patient Assignment: Is Anyone There?
Citation Text:
Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/49865/psn-pdf
June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy
June 1, 2019
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
The Case
A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
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www.ahrq.gov/sites/default/files/2024-11/kowozer-report.pdf
January 01, 2024 - Final Progress Report: Mortality Assessment in Lung Cancer Resection
Final Progress Report
Mortality Assessment in Lung Cancer Resection
University of Virginia
July 1, 2009 – June 30, 2014
Principal Investigator: Benjamin D. Kozower, MD, MPH
Project Officer: Kay Anderson, PhD
I would like to …
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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - Errors in Sepsis Management
May 1, 2015
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/errors-sepsis-management
Case Objectives
Define sepsis, severe sepsis, and septic shock.
Describe the severe sepsis/septic shock resuscitation bundle.
Recognize commonly encou…