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8281. Delirium or Dementia? | PSNet
      psnet.ahrq.gov/web-mm/delirium-or-dementia
      September 27, 2023 - SPOTLIGHT CASE Delirium or Dementia? Citation Text: Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…

8282. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50698/psn-pdf
      November 27, 2019 - Missed Opportunities for Suicide Risk Assessment November 27, 2019 Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…

8283. Not-So-Therapeutic Tap | PSNet
      psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
      December 01, 2014 - SPOTLIGHT CASE Not-So-Therapeutic Tap Citation Text: Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

8284. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33873/psn-pdf
      February 01, 2019 - In Conversation With… Susan E. Skochelak, MD, PhD February 1, 2019 In Conversation With… Susan E. Skochelak, MD, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd Editor's note: Dr. Skochelak is the Group Vice President for Medical Education at the American Medica…

8285. In Conversation With… David Blumenthal, MD, MPP | PSNet
      psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
      March 27, 2024 - The best examples were Kaiser, Cleveland Clinic, and Johns Hopkins.

8286. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33644/psn-pdf
      December 01, 2006 - Establishing a Safety Culture: Thinking Small December 1, 2006 Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small Perspective Safety cultures are the holy grail in any risky industry. Like all holy grails, th…

8287. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50931/psn-pdf
      February 26, 2020 - Timely diagnosis of esophageal perforation February 26, 2020 Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation The Case  A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…

8288. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866621/psn-pdf
      August 28, 2024 - Application of Safety-II Principles August 28, 2024 Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/application-safety-ii-principles Traditional approaches to patient safety have often been reactive rather than proactive, seeki…

8289. Confusion With Acetaminophen | PSNet
      psnet.ahrq.gov/web-mm/confusion-acetaminophen
      December 01, 2009 - Confusion With Acetaminophen Citation Text: Heubi JE. Confusion With Acetaminophen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

8290. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33778/psn-pdf
      March 01, 2015 - Diagnostic Errors January 1, 2014 Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/diagnostic-errors Annual Perspective 2014 Until very recently, diagnostic errors received relatively little attention in the field of patient safety, particularly when compared wi…

8291. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
      November 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfusion Overload 1 2 Source and Credits This presentation is based on the November 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Manish S. Patel, MD, and Jeffrey L. Carson, MD, of UMDNJ−Robert Wood …

8292. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49409/psn-pdf
      July 01, 2003 - Feeling No Pain July 1, 2003 Bogner MS. Feeling No Pain. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/feeling-no-pain The Case A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…

8293. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60548/psn-pdf
      May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD May 28, 2020 In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food…

8294. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49590/psn-pdf
      January 01, 2010 - Is the Admission Drug Dose Too Low? August 1, 2009 Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low The Case A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to the hospit…

8295. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49634/psn-pdf
      September 01, 2011 - Situational (Un)Awareness September 1, 2011 Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/situational-unawareness The Case A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver function tests, including a bi…

8296. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33761/psn-pdf
      February 01, 2014 - Interruptions and Distractions in Health Care: Improved Safety With Mindfulness February 1, 2014 Beyea SC. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulne…

8297. Missed Nursing Care | PSNet
      psnet.ahrq.gov/primer/missed-nursing-care
      September 15, 2024 - Missed Nursing Care Citation Text: Missed Nursing Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

8298. Informed or Misled? | PSNet
      psnet.ahrq.gov/web-mm/informed-or-misled
      April 24, 2018 - Informed or Misled? Citation Text: White SM. Informed or Misled? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…

8299. Human Factors Engineering Can Teach You How to Be Surprised Again | PSNet
      psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
      November 01, 2006 - The hospital or clinic would instinctively think of calling in experts in design and human factors and

8300. What Makes a Good Checklist | PSNet
      psnet.ahrq.gov/perspective/what-makes-good-checklist
      October 01, 2010 - staff that, "All you anesthesiologists want to do is cancel cases and you're going to make me late for clinic