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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - Statewide Telehealth Program Enhances Access to Care,
Improves Outcomes for High-Risk Pregnancies in Rural
Area
June 12, 2020
https://psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-
high-risk
Summary
Formerly known as the Antenatal and Neonatal Guidelines, Education…
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psnet.ahrq.gov/issue/emergency-diagnosis-cancer-and-previous-general-practice-consultations-insights-linked
February 17, 2021 - Study
Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data.
Citation Text:
Abel GA, Mendonca SC, McPhail S, et al. Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey…
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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/node/61044/psn-pdf
January 01, 2021 - Seven features of safety in maternity units: a framework
based on multisite ethnography and stakeholder
consultation.
October 21, 2020
Liberati EG, Tarrant C, Willars J, et al. Seven features of safety in maternity units: a framework based on
multisite ethnography and stakeholder consultation. BMJ Qual Saf. 2021;3…
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - retrospect appears to have been misdiagnosed by the ED physician, radiologist, and first pulmonary consultant … Unfortunately, the initial pulmonary consultant in this case apparently did not consider the potential
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psnet.ahrq.gov/issue/10-leadership-mindsets-high-reliability-organizations-how-empower-caregivers-and-engage
August 12, 2020 - Newspaper/Magazine Article
10 Leadership mindsets for high reliability organizations. How to empower caregivers and engage patients in patient safety.
Citation Text:
10 Leadership mindsets for high reliability organizations. How to empower caregivers and engage patients in patient safety…
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psnet.ahrq.gov/node/853234/psn-pdf
September 06, 2023 - Perceptions and attitudes of pediatricians and families
with regard to pediatric medication errors at home.
September 6, 2023
de Dios JG, Lopez-Pineda A, Juan GM-P, et al. Perceptions and attitudes of pediatricians and families with
regard to pediatric medication errors at home. BMC Pediatr. 2023;23(1):380. doi:10.…
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psnet.ahrq.gov/node/73219/psn-pdf
May 05, 2021 - Clinical supervision in general practice training: the
interweaving of supervisor, trainee and patient
entrustment with clinical oversight, patient safety and
trainee learning.
May 5, 2021
Sturman N, Parker M, Jorm C. Clinical supervision in general practice training: the interweaving of
supervisor, trainee and p…
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psnet.ahrq.gov/node/60278/psn-pdf
April 29, 2020 - Assessing patient safety in a pediatric telemedicine
setting: a multi-methods study.
April 29, 2020
Haimi M, Brammli-Greenberg S, Baron-Epel O, et al. Assessing patient safety in a pediatric telemedicine
setting: a multi-methods study. BMC Med Inform Decis Mak. 2020;20(1). doi:10.1186/s12911-020-1074-7.
https://ps…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
June 01, 2014 - Smith, CHPA, CPP, President, Healthcare Security Consultants, Inc.
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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - Cost is also a barrier to CPOE implementation, with implementation costs (including software, consultants
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psnet.ahrq.gov/issue/seven-features-safety-maternity-units-framework-based-multisite-ethnography-and-stakeholder
February 20, 2019 - Study
Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder consultation.
Citation Text:
Liberati EG, Tarrant C, Willars J, et al. Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder con…
-
psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - In cases in which capacity is questionable, the provider must enlist the aid of a consultant with expertise … Capacity reflects a spectrum of decision-making ability and providers should enlist the help of a consultant
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psnet.ahrq.gov/node/853981/psn-pdf
September 27, 2023 - orientation and/or recall
memory, even if other cortical functions are preserved.2,3 The psychiatry consultant
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psnet.ahrq.gov/node/48083/psn-pdf
August 07, 2019 - Missed diagnosis of cancer in primary care: insights from
malpractice claims data.
August 7, 2019
Aaronson E, Quinn GR, Wong CI, et al. Missed diagnosis of cancer in primary care: Insights from
malpractice claims data. J Healthc Risk Manag. 2019;39(2):19-29. doi:10.1002/jhrm.21385.
https://psnet.ahrq.gov/issue/mis…
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psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - delineate precisely how responsibility for care is handed off from the ED to admitting physicians and consultants
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - In cases in which capacity is questionable,
the provider must enlist the aid of a consultant with expertise … Capacity reflects a spectrum of decision-making ability and providers
should enlist the help of a consultant
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - Some radiology departments designate a radiologist, fellow, or resident as the consultant of the day
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Spotlight
Spotlight
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
1
Source and Credits
This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Samantha Brown…
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psnet.ahrq.gov/issue/healthcare-inspection-evaluation-veterans-health-administrations-national-consult-delay
September 10, 2014 - Book/Report
Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.
Citation Text:
Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.…