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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - The Consequences of Miscommunication Regarding a
Possible Artifact
June 30, 2021
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
Disclosure of Relevant Financial Relationships…
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psnet.ahrq.gov/node/854848/psn-pdf
October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures
October 31, 2023
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
The Case
A 32-year-old man presented to the hospital with…
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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - Check the Wristband
July 1, 2003
Rosenthal M. Check the Wristband. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/check-wristband
The Case
The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the
impending surgery. The patient spoke English and appeared to be of aver…
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered
Nurses and Paramedics To Provide Home Visits to
Recently Discharged Patients at Highest Risk for Hospital
Readmission
April 7, 2022
https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-
paramedics-provide-home
Sum…
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting
firm …
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psnet.ahrq.gov/node/33635/psn-pdf
July 01, 2006 - In Conversation with...Allan Frankel, MD
July 1, 2006
In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this
kind of work.
Dr. Allan …
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psnet.ahrq.gov/node/33865/psn-pdf
September 01, 2018 - In Conversation With… Rebecca Lawton, PhD
September 1, 2018
In Conversation With… Rebecca Lawton, PhD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
Editor's note: Rebecca Lawton, a Professor in the Psychology of Healthcare at the University of Leeds, is
a health psycho…
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psnet.ahrq.gov/node/49642/psn-pdf
December 01, 2011 - Order Interrupted by Text: Multitasking Mishap
December 1, 2011
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
Case Objectives
State the prevalence of mobile devices among clinicians and their common health…
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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx
Spotlight
Challenging Case of Multiple Suicide Attempts in a
Complex Patient with Psychiatric Comorbidities
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - Dangerous Shift
November 1, 2008
Patterson ES. Dangerous Shift. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/dangerous-shift
Case Objectives
Review the evidence base on erroneous actions related to shift changes.
Understand the limits of standardizing handoffs in preventing errors at shift change.
Expla…
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psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
May 11, 2019 - SPOTLIGHT CASE
The Consequences of Miscommunication Regarding a Possible Artifact
Citation Text:
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - Coming Undone: Failure of Closure Device
Citation Text:
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar Bi…
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psnet.ahrq.gov/web-mm/failure-latch
November 27, 2012 - Failure to Latch
Citation Text:
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/node/60790/psn-pdf
February 23, 2022 - dental organizations may have dental operatories that are clustered in open spaces
without physical barriers
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - Barriers and facilitators to chemotherapy patients' engagement in medical error prevention.
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psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - services, and use of interpreting services, should be enlisted to overcome any cultural and linguistic
barriers
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - physician or the healthcare system
– System-related errors, which include technological or organizational
barriers
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - depend on many of the factors previously
mentioned, including perceived threats and benefits, perceived barriers
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psnet.ahrq.gov/node/49750/psn-pdf
January 01, 2016 - //psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
with the staff nurse to address barriers
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - A Case of Medication Error and Recovery
January 31, 2024
Facilitators and barriers