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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - SPOTLIGHT CASE
The Perils of Cross Coverage
Citation Text:
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis.
Citation Text:
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - Misplaced Nasogastric Tube Resulting in Aspiration
Citation Text:
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - Right as you’re preparing to the leave the hospital, there is so much new information to be aware of,
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
January 01, 2021 - .
– Use the PDMP prior to any prescribing for controlled substances, aware of
its limitations.
– Try
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
July 01, 2012 - Doing so requires that we are aware when we err, and sometimes this is not easy to do.
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psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
July 01, 2012 - Doing so requires that we are aware when we err, and sometimes this is not easy to do.
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psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
March 01, 2017 - You were well aware of the possibility that this complex intervention depended on a lot of nuanced things
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psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
August 01, 2019 - have for scribes and documents that both the scribe and the physician using the scribe have been made aware
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psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
July 01, 2017 - the patient safety movement and additional research on the causality of medical error, we become more aware
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psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
August 01, 2018 - Health care executives, insurance companies, regulators, and other opinion leaders must be made more aware
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psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
August 01, 2018 - Health care executives, insurance companies, regulators, and other opinion leaders must be made more aware
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - would be to “add a flag to the EHR for similar test results so that clinicians are automatically made aware
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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - I'm not aware of another health care service that varies by a full order of magnitude.
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psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-disciplinary-actions-and-complaints-what-do-we-know
July 01, 2017 - the patient safety movement and additional research on the causality of medical error, we become more aware
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psnet.ahrq.gov/node/867986/psn-pdf
March 24, 2025 - This new emphasis from The Joint Commission
will hopefully make sure that more people are aware and
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - would be to “add a flag to the EHR for similar test results so that clinicians are automatically made aware
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - Right as you’re preparing to the leave the hospital, there is so much new information to be aware of,
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - SPOTLIGHT CASE
A Laceration that Needed a Proper Exam, Not an X-Ray
Citation Text:
Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care
Following Cesarean Delivery.
November 25, 2020
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean
Delivery. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesare…