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psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - Misconnection Leading to Arterial Thrombosis
Citation Text:
Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - SPOTLIGHT CASE
A Lot of Pain (Medications)
Citation Text:
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/853245/psn-pdf
September 06, 2023 - Intraoperative communications between pathologists and
surgeons: do we understand each other?
September 6, 2023
Wiggett A, Fischer G. Intraoperative communications between pathologists and surgeons: do we
understand each other? Arch Pathol Lab Med. 2023;147(8):933-939. doi:10.5858/arpa.2020-0632-oa.
https://psnet.…
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psnet.ahrq.gov/node/838187/psn-pdf
September 28, 2022 - Diagnostic delays in infectious diseases.
September 28, 2022
Suneja M, Beekmann SE, Dhaliwal G, et al. Diagnostic delays in infectious diseases. Diagnosis (Berl).
2022;9(3):332-339. doi:10.1515/dx-2021-0092.
https://psnet.ahrq.gov/issue/diagnostic-delays-infectious-diseases
Delayed diagnosis of infectious diseases…
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psnet.ahrq.gov/node/43949/psn-pdf
November 17, 2016 - Clinical criteria to screen for inpatient diagnostic errors: a
scoping review.
November 17, 2016
Shenvi EC, El-Kareh R. Clinical criteria to screen for inpatient diagnostic errors: a scoping review.
Diagnosis (Berl). 2015;2(1):3-19. doi:10.1515/dx-2014-0047.
https://psnet.ahrq.gov/issue/clinical-criteria-screen-in…
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psnet.ahrq.gov/node/46527/psn-pdf
March 07, 2018 - When missing a 'zebra' can land you in court.
March 7, 2018
Crane M. Medscape Business of Medicine. February 20, 2018.
https://psnet.ahrq.gov/issue/when-missing-zebra-can-land-you-court
Cognitive biases contribute to missed diagnoses. This article discusses how cognitive biases affect
decision making associated wi…
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psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one
March 01, 2005 - communication between the pump user and hospital staff, including practitioners on the primary team, diabetes consultants
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psnet.ahrq.gov/node/865570/psn-pdf
April 10, 2024 - Risk Mitigation Using the Anesthesia Risk Alert Program:
Applying a Proactive Approach With Data Review &
Collaborating With a Second Practitioner
April 10, 2024
https://psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-
approach-data
Summary
North American Partners…
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psnet.ahrq.gov/node/865972/psn-pdf
May 29, 2024 - Development and evaluation of patient safety
interventions: perspectives of operational safety leaders
and patient safety organizations.
May 29, 2024
Gomes KM, Handley J, Pruitt ZM, et al. Development and evaluation of patient safety interventions:
perspectives of operational safety leaders and patient safety orga…
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psnet.ahrq.gov/issue/variations-gps-decisions-investigate-suspected-lung-cancer-factorial-experiment-using
August 03, 2022 - Study
Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes.
Citation Text:
Sheringham J, Sequeira R, Myles J, et al. Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia …
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psnet.ahrq.gov/node/861738/psn-pdf
January 31, 2024 - //#13
https://psnet.ahrq.gov//#8
Referral and Follow-up
Depending on local practice patterns and consultant
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psnet.ahrq.gov/node/73372/psn-pdf
June 09, 2021 - Impact of COVID-19 on inpatient clinical emergencies: a
single-center experience.
June 9, 2021
Mitchell OJL, Neefe S, Ginestra JC, et al. Impact of COVID-19 on inpatient clinical emergencies: a single-
center experience. Resusc Plus. 2021;6:100135. doi:10.1016/j.resplu.2021.100135.
https://psnet.ahrq.gov/issue/imp…
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psnet.ahrq.gov/node/837510/psn-pdf
June 22, 2022 - In situ simulation for adoption of new technology to
improve sepsis care in rural emergency departments.
June 22, 2022
Powell ES, Bond WF, Barker LT, et al. In situ simulation for adoption of new technology to improve sepsis
care in rural emergency departments. J Patient Saf. 2022;18(4):302-309.
doi:10.1097/pts.00…
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psnet.ahrq.gov/node/47840/psn-pdf
July 31, 2019 - Development and performance evaluation of the
Medicines Optimisation Assessment Tool (MOAT): a
prognostic model to target hospital pharmacists' input to
prevent medication-related problems.
July 31, 2019
Geeson C, Wei L, Franklin BD. Development and performance evaluation of the Medicines Optimisation
Assessment …
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psnet.ahrq.gov/node/36198/psn-pdf
March 28, 2011 - Using human error theory to explore the supply of non-
prescription medicines from community pharmacies.
March 28, 2011
Watson MC, Bond CM, Johnston M, et al. Using human error theory to explore the supply of non-
prescription medicines from community pharmacies. Qual Saf Health Care. 2006;15(4):244-50.
https://ps…
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psnet.ahrq.gov/node/41107/psn-pdf
May 04, 2012 - A prospective, multicenter study of pharmacist activities
resulting in medication error interception in the
emergency department.
May 4, 2012
Patanwala AE, Sanders AB, Thomas MC, et al. A prospective, multicenter study of pharmacist activities
resulting in medication error interception in the emergency department.…
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psnet.ahrq.gov/node/37118/psn-pdf
October 04, 2011 - Knowledge translation in critical care: factors associated
with prescription of commonly recommended best
practices for critically ill patients.
October 4, 2011
Ilan R, Fowler RA, Geerts R, et al. Knowledge translation in critical care: factors associated with
prescription of commonly recommended best practices fo…
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psnet.ahrq.gov/node/34661/psn-pdf
March 07, 2005 - Teaching smart people how to learn.
March 7, 2005
Argyris C. Harvard Business Review. 1991:69(May-June):99+.
https://psnet.ahrq.gov/issue/teaching-smart-people-learn
Argyris, a Harvard Business School professor, theorizes that companies and organizations must learn in
order to continually improve and succeed, but …
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psnet.ahrq.gov/node/74240/psn-pdf
January 01, 2024 - Use and impact of virtual primary care on quality and
safety: the public's perspectives during the COVID-19
pandemic.
January 12, 2022
Neves AL, van Dael J, O’Brien N, et al. Use and impact of virtual primary care on quality and safety: The
public's perspectives during the COVID-19 pandemic. J Telemed Telecare. 20…
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psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
Discharged with IV antibiotics:
When issues arise, who manages
the complications?
Source and Credits
• This presentation is based on the February 2020 AHRQ
WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Monica Donnel…