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1661. Psn-Pdf (pdf file)
      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…

1662. Missed Patient Assignment: Is Anyone There? | PSNet
      psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
      September 01, 2017 - Missed Patient Assignment: Is Anyone There? Citation Text: Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google …

1663. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
      June 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfer Troubles 1 2 Source and Credits This presentation is based on the June 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…

1664. Getting Started with a Communication and Resolution Program (CRP) Policy or Commitment Statement to CR. | PSNet
      psnet.ahrq.gov/issue/getting-started-communication-and-resolution-program-crp-policy-or-commitment-statement-cr
      February 28, 2024 - Tools/Toolkit Getting Started with a Communication and Resolution Program (CRP) Policy or Commitment Statement to CR. Citation Text: Getting Started with a Communication and Resolution Program (CRP) Policy or Commitment Statement to CR. Collaborative for Accountability and Improvement Po…

1665. Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview. | PSNet
      psnet.ahrq.gov/issue/nurses-perceptions-and-experiences-communication-operating-theatre-focus-group-interview
      June 22, 2009 - Study Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview. Citation Text: Nestel D, Kidd J. Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview. BMC Nurs. 2006;5:1. Copy Citation …

1666. Increasing patient safety and surgical team communication by using a count/time out board. | PSNet
      psnet.ahrq.gov/issue/increasing-patient-safety-and-surgical-team-communication-using-counttime-out-board
      February 22, 2012 - Commentary Increasing patient safety and surgical team communication by using a count/time out board. Citation Text: Edel EM. Increasing patient safety and surgical team communication by using a count/time out board. AORN J. 2010;92(4):420-4. doi:10.1016/j.aorn.2010.03.013. Copy Cita…

1667. Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace. | PSNet
      psnet.ahrq.gov/issue/improving-healthcare-team-communication-building-lessons-aviation-and-aerospace
      August 08, 2007 - Book/Report Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace. Citation Text: Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace. Nemeth CP, ed. Burlington, VT: Ashgate Publishing; 2008. ISBN: 9780754670254. C…

1668. How communications issues between doctors and nurses can affect your health. | PSNet
      psnet.ahrq.gov/issue/how-communications-issues-between-doctors-and-nurses-can-affect-your-health
      September 28, 2016 - Newspaper/Magazine Article How communications issues between doctors and nurses can affect your health. Citation Text: How communications issues between doctors and nurses can affect your health. Howley EK. US News & World Report. September 5, 2018. Copy Citation Save …

1669. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33691/psn-pdf
      December 01, 2009 - How to Identify and Manage Problem Behaviors December 1, 2009 Rosenstein AH, O'Daniel M. How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors Perspective The 1999 Institute of Medicine report highlighted the need for heal…

1670. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49703/psn-pdf
      March 01, 2014 - After-Visit Confusion March 1, 2014 Ventres W. After-Visit Confusion. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/after-visit-confusion The Case An otherwise healthy 18-year-old woman presented to an urgent care clinic with new bumps and white spots near her tongue. The patient's mother accompanied her …

1671. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33681/psn-pdf
      March 01, 2009 - The Role of Health Literacy in Patient Safety March 1, 2009 Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/role-health-literacy-patient-safety Perspective Clear health communication is increasingly recognized as essential for promoting …

1672. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46263/psn-pdf
      July 12, 2017 - The texting debate: beneficial means of communication or safety and security risk? July 12, 2017 ISMP Medication Safety Alert! Acute Care Edition. June 29, 2017;16:1-5. https://psnet.ahrq.gov/issue/texting-debate-beneficial-means-communication-or-safety-and-security-risk Adopting new technologies in health care ca…

1673. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50591/psn-pdf
      January 01, 2020 - Secure text messaging in healthcare: latent threats and opportunities to improve patient safety. October 30, 2019 Hagedorn PA, Singh A, Luo B, et al. Secure Text Messaging in Healthcare: Latent Threats and Opportunities to Improve Patient Safety. J Hosp Med. 2020;15(6):378-380. doi:10.12788/jhm.3305. https://psnet…

1674. Moving Pains | PSNet
      psnet.ahrq.gov/web-mm/moving-pains
      August 17, 2017 - In this case, the hospital did have a system for assessing and communicating the clinical stability of

1675. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
      November 01, 2003 - Spotlight Case [MONTH] 2003 Spotlight Case November 2003 The Missing Suction Tip Source and Credits This presentation is based on the Nov. 2003 AHRQ WebM&M Spotlight Case in Surgery See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Eric J. Thomas, MD,…

1676. A Tale of Two Falls | PSNet
      psnet.ahrq.gov/web-mm/tale-two-falls
      March 27, 2024 - Secure instant messages within the EHR can be a useful tool for communicating or clarifying information

1677. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73995/psn-pdf
      October 20, 2021 - Potential for medication overdose with ENFit low dose tip syringe: FDA Safety Communication. October 20, 2021 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 12, 2021. https://psnet.ahrq.gov/issue/potential-medication-overdose-enfit-low-dose-tip-syringe-fda-safety- communication …

1678. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44791/psn-pdf
      January 13, 2016 - FDA Drug Safety Communication: FDA cautions about dosing errors when switching between different oral formulations of antifungal Noxafil (posaconazole); label changes approved. January 13, 2016 US Food and Drug Administration; FDA. https://psnet.ahrq.gov/issue/fda-drug-safety-communication-fda-cautions-about-dosi…

1679. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46548/psn-pdf
      April 16, 2018 - Nurses' communication of safety events to nursing home residents and families. April 16, 2018 Wagner LM, Driscoll L, Darlington JL, et al. Nurses' Communication of Safety Events to Nursing Home Residents and Families. J Gerontol Nurs. 2018;44(2):25-32. doi:10.3928/00989134-20171002-01. https://psnet.ahrq.gov/issue…

1680. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37981/psn-pdf
      June 16, 2011 - Nurses' perceptions of error communication and reporting in the intensive care unit. June 16, 2011 Elder NC, Brungs SM, Nagy M, et al. Nurses' Perceptions of Error Communication and Reporting in the Intensive Care Unit. J Patient Saf. 2008;4(3). doi:10.1097/pts.0b013e3181839b48. https://psnet.ahrq.gov/issue/nurses…