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psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - The "Customer" Is Always Right
February 1, 2007
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/customer-always-right
Case Objectives
Understand the importance of identifying a patient's agenda.
Appreciate the factors that contribute to unmet patient expectations.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
January 01, 2019 - Spotlight
Spotlight
Mistaken Attribution, Diagnostic Misstep
*
Source and Credits
This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - Wrong Catheter in the Right Patient
Citation Text:
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - SPOTLIGHT CASE
When the Indications for Drug Administration Blur
Citation Text:
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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…
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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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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - SPOTLIGHT CASE
The Other Side
Citation Text:
Vincent CA. The Other Side. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters
Citation Text:
Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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Format:
Google S…
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psnet.ahrq.gov/node/49705/psn-pdf
January 01, 2020 - A "Reflexive" Diagnosis in Primary Care
April 1, 2014
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
Case Objectives
Appreciate that primary care doctors may be caring for an increasing number of patients wi…
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psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
September 24, 2024 - Statistically, patient harm is rare enough that reliably assessing whether a harm is preventable or not
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - SPOTLIGHT CASE
A Stroke of Error
Citation Text:
Barrett KM. A Stroke of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/44434/psn-pdf
June 21, 2016 - Hospital board and management practices are strongly
related to hospital performance on clinical quality
metrics.
June 21, 2016
Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to
hospital performance on clinical quality metrics. Health Aff (Millwood). 2015;34(8):130…
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psnet.ahrq.gov/node/46296/psn-pdf
September 24, 2017 - Perception of safety of surgical practice among operating
room personnel from survey data is associated with all-
cause 30-day postoperative death rate in South Carolina.
September 24, 2017
Molina G, Berry WR, Lipsitz S, et al. Perception of Safety of Surgical Practice Among Operating Room
Personnel From Survey Da…
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psnet.ahrq.gov/node/39617/psn-pdf
February 18, 2011 - Potential unintended consequences due to Medicare's
"No Pay for Errors Rule"? A randomized controlled trial of
an educational intervention with internal medicine
residents.
February 18, 2011
Mookherjee S, Vidyarthi AR, Ranji SR, et al. Potential Unintended Consequences Due to Medicare’s “No
Pay for Errors Rule”? …
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psnet.ahrq.gov/issue/safemedicationuseca
October 10, 2012 - Multi-use Website
SafeMedicationUse.ca.
Citation Text:
SafeMedicationUse.ca. Institute for Safe Medication Practices Canada; ISMP Canada.
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psnet.ahrq.gov/node/47117/psn-pdf
November 16, 2018 - Using a pediatric trigger tool to estimate total harm
burden hospital-acquired conditions represent.
November 16, 2018
Stockwell DC, Landrigan CP, Schuster MA, et al. Using a Pediatric Trigger Tool to Estimate Total Harm
Burden Hospital-acquired Conditions Represent. Pediatr Qual Saf. 2018;3(3):e081.
doi:10.1097/p…
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psnet.ahrq.gov/node/40578/psn-pdf
July 06, 2011 - Implementing the 2009 Institute of Medicine
recommendations on resident physician work hours,
supervision, and safety.
July 6, 2011
Blum AB, Shea AS, Czeisler CA, et al. Implementing the 2009 Institute of Medicine recommendations on
resident physician work hours, supervision, and safety. Nat Sci Sleep. 2011;3:47-8…
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psnet.ahrq.gov/node/42151/psn-pdf
December 21, 2014 - Effect of the 2011 vs 2003 duty hour regulation-compliant
models on sleep duration, trainee education, and
continuity of patient care among internal medicine house
staff: a randomized trial.
December 21, 2014
Desai SV, Feldman LS, Brown L, et al. Effect of the 2011 vs 2003 Duty Hour Regulation–Compliant Models
on…
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psnet.ahrq.gov/node/43801/psn-pdf
August 02, 2015 - Association of the 2011 ACGME resident duty hour reform
with general surgery patient outcomes and with resident
examination performance.
August 2, 2015
Rajaram R, Chung JW, Jones AT, et al. Association of the 2011 ACGME resident duty hour reform with
general surgery patient outcomes and with resident examination p…
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psnet.ahrq.gov/node/39714/psn-pdf
April 14, 2011 - US public opinion regarding proposed limits on resident
physician work hours.
April 14, 2011
Blum AB, Raiszadeh F, Shea S, et al. US public opinion regarding proposed limits on resident physician
work hours. BMC Med. 2010;8:33. doi:10.1186/1741-7015-8-33.
https://psnet.ahrq.gov/issue/us-public-opinion-regarding-pr…