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  1. psnet.ahrq.gov/sites/default/files/2020-04/spotlight-slides-wright-schiff.pdf
    January 01, 2020 - Spotlight The Lost Start Date, an Unknown Risk of E-prescribing Source and Credits • This presentation is based on the October 2019 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Adam Wright, PhD, and Gordon Schiff, MD ○ Editor, AHRQ…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33592/psn-pdf
    December 15, 2024 - Adverse Events, Near Misses, and Errors December 15, 2024 Adverse Events, Near Misses, and Errors. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current re…
  3. psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
    January 01, 2019 - Spotlight Missed Opportunities for Suicide Risk Assessment Source and Credits • This presentation is based on the November 2019 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Glen Xiong, MD & Debra Kahn, MD ○ Editors in Chief, AHRQ We…
  4. psnet.ahrq.gov/web-mm/medication-mix-bad-worse
    March 01, 2018 - have the potential to intercept drug name confusion errors.( 6 ) In such alerts, the CPOE notifies the clinician
  5. psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
    August 15, 2017 - Perils in Diagnosing a Stroke Citation Text: Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
  6. psnet.ahrq.gov/web-mm/more-treatment-better-care
    August 11, 2021 - More Treatment—Better Care? Citation Text: Redberg R. More Treatment—Better Care?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
  7. psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
    August 01, 2006 - process.( 2 ) Practices to enhance the handoff included: both the incoming as well as the outgoing clinician
  8. psnet.ahrq.gov/web-mm/too-tight-control
    March 20, 2013 - SPOTLIGHT CASE Too Tight Control Citation Text: Rubin HR, Fajtova VT. Too Tight Control. 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…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49570/psn-pdf
    October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure? October 1, 2008 Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure Case Objectives Understand the complementary abilities of an electronic health record a…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49639/psn-pdf
    November 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33738/psn-pdf
    December 01, 2012 - In Conversation With... John G. Reiling, PhD December 1, 2012 In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd Editor's note: John G. Reiling, PhD, is president and CEO of Safe by Design. Dr. Reiling consults with hospitals and…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841139/psn-pdf
    December 14, 2022 - Clinician ratings of interpreter mediated visits in underserved primary care settings with ad hoc, in-person
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843151/psn-pdf
    February 01, 2023 - Patient Safety Concerns and the LGBTQ+ Population February 1, 2023 Wesley C, Van CM, Mossburg S. Patient Safety Concerns and the LGBTQ+ Population. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/patient-safety-concerns-and-lgbtq-population Challenges to Obtaining Needed Patient-Centered and Safe Health…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33746/psn-pdf
    March 01, 2013 - reap the benefits of some things they've done while retaining the flexibility and resiliency and the clinician–patient
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49699/psn-pdf
    February 01, 2014 - Multifactorial Medication Mishap February 1, 2014 Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap Case Objectives Understand the system-based causes of medication errors. Describe a model for a systems approach to error analysis. Id…
  17. 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://…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49485/psn-pdf
    August 29, 2024 - Blind Spot June 1, 2005 Lee LA. Blind Spot. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/blind-spot The Case A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33875/psn-pdf
    March 01, 2019 - www.ariadnelabs.org/safe-expansion/ https://www.ariadnelabs.org/safe-expansion/ https://www.rmf.harvard.edu/Clinician-Resources
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33818/psn-pdf
    November 01, 2016 - RW: Another theme over the last several years has been growing rates of clinician burnout, and there

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