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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - A Stroke of Error
December 1, 2014
Barrett KM. A Stroke of Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/stroke-error
Case Objectives
State the key clinical factors to assess in a patient with suspected stroke.
Appreciate the relationship between elevated blood pressure and stroke in the acute sett…
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psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - SPOTLIGHT CASE
A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care.
Citation Text:
Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
January 01, 2024 - Spotlight
Hindsight is 20/20: Thrombolytics for Alcohol
Intoxication
Source and Credits
• This presentation is based on the April 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Eric Signoff, MD, Noelle Boctor, MD, and David K.
B…
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psnet.ahrq.gov/node/846171/psn-pdf
July 26, 2022 - Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
March 15, 2023
Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of
Gastric Perforation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/agitated-delirium-contributes…
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psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
October 02, 2024 - Safety I, Safety II, and the New Views of Safety
Citation Text:
Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
Copy Citation
Format:
Google Scholar BibTeX E…
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/perspective/workplace-safety-health-care
January 01, 2017 - China, Hungary, or any place in the world, as long as we were working in real time, with the advent of computer
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psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
January 01, 2015 - But you're right, everyone complains about their computer systems. That's pretty universal.
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psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
May 01, 2019 - The computer or the machine tells them what it thinks it is, but they're expected to look at the record
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psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
August 31, 2020 - American College of Radiology Recommendations for the use of Chest Radiography and Computer Tomography
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psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
December 01, 2006 - culture
The permanent culture change that results
Existing culture remains
Resident teams use a computer
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psnet.ahrq.gov/node/60242/psn-pdf
March 01, 2021 - approval: Once the care plan is developed, the
support team meets with the patient's PCP to review a computer-generated
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psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
January 01, 2017 - China, Hungary, or any place in the world, as long as we were working in real time, with the advent of computer
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psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
May 01, 2019 - The computer or the machine tells them what it thinks it is, but they're expected to look at the record
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psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
March 01, 2008 - At the front end there's a scheduler, someone who takes the calls, pulls new orders from the computer
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - culture
The permanent culture change that results
Existing culture remains
Resident teams use a computer
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psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
January 01, 2015 - But you're right, everyone complains about their computer systems. That's pretty universal.
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psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
October 24, 2021 - Or is it a reliance on the use of interoperable computer systems?
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - SPOTLIGHT CASE
Premature Closure: Was It Just Syncope?
Citation Text:
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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…
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psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
December 18, 2024 - SPOTLIGHT CASE
Hindsight is 20/20: Thrombolytics for Alcohol Intoxication
Citation Text:
Hindsight is 20/20: Thrombolytics for Alcohol Intoxication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
Copy Citation
…