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psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
January 01, 2021 - Spotlight
Spotlight
Two Cases of Retained Vaginal Packing:
When Writing an Order is Not Enough
Source and Credits
• This presentation is based on the April 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Verna Gibbs, MD
o AHRQ W…
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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/web-mm/crossing-line
December 01, 2012 - SPOTLIGHT CASE
Crossing the Line
Citation Text:
Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote…
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement
Carole Stockmeier, MHA, BS, Eric Thomas, MD, MPH, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD | September 24, 2024
Also Read the Conversations
In Conversation with Ca…
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - include apnea, hypoxia,
vomiting, aspiration, laryngospasm, cardiovascular collapse, and adverse
behavioral
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psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
March 01, 2008 - Components of the MPS Address All Levels of Miller's Pyramid (Go to table citation in commentary)
Behavioral
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psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - simulations , discussions) are more effective for retaining information and supporting attitude and behavioral
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psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
November 16, 2022 - the end-user to improve performance, safety, and efficiency, using psychology, sociology, and other behavioral
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psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - simulations , discussions) are more effective for retaining information and supporting attitude and behavioral
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care
Source and Credits
• This presentation is based on the 2020 AHRQ WebM&M Spotlight
Case
○ See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD
○ Editor…
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psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - Hidden Mystery
March 1, 2005
Brunette DD. Hidden Mystery. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hidden-mystery
Case Objectives
Appreciate the challenges of caring for morbidly obese patients.
List specific interventions that can be implemented when caring for obese patients.
Develop a rational ap…
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psnet.ahrq.gov/node/841305/psn-pdf
January 27, 2023 - In Conversation with... Ellen Deutsch, MD, MS, FACS,
FAAP, FSSH, CPPS
December 14, 2022
In Conversation with.. Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
Editor’s Note: Ellen Deutsch, MD, MS, FACS, F…
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the
Senior Clinical Data Analyst at Atrium Health, and Rhonda
Dickman, MSN, RN, CPHQ, the Director of the Tennessee
Hospital Association PSO
January 12, 2022
In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and
Rhonda…
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psnet.ahrq.gov/node/33837/psn-pdf
July 01, 2017 - In Conversation With… Michelle Mello, MPhil, JD, PhD
July 1, 2017
In Conversation With… Michelle Mello, MPhil, JD, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
Editor's note: Michelle Mello is Professor of Law at Stanford Law School and Professor of Healt…
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psnet.ahrq.gov/node/33842/psn-pdf
January 01, 2018 - Assessing the Safety of Electronic Health Records: What
Have We Learned?
September 1, 2017
Sittig DF, Singh H. Assessing the Safety of Electronic Health Records: What Have We Learned? PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
Perspec…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest
Citation Text:
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - Debriefing for Clinical Learning
November 18, 2021
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/debriefing-clinical-learning
Updated in September 2021. Originally published in December 2011 by researchers at the University of
California, S…
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Browse Author Resources
Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …