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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - Critical Echocardiogram Result Lost to Follow-up
Citation Text:
Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up.. 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/perspective/missed-nursing-care-key-measure-patient-safety
March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety
Jane Ball, PhD, and Peter Griffiths, PhD | March 1, 2018
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Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient…
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psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again
John Gosbee, MD, MS | November 1, 2006
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Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Aga…
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psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - Interpreting the Patient Safety Literature
Kaveh G. Shojania, MD | June 1, 2005
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Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/node/853774/psn-pdf
September 27, 2023 - Delayed Evaluation of Abdominal Pain in an Elderly
Patient.
September 27, 2023
Klimkiv L, Utter GH, Barnes DK. Delayed Evaluation of Abdominal Pain in an Elderly Patient. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
The Case
An 85-year-old woman presente…
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psnet.ahrq.gov/node/867428/psn-pdf
December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing
Journey to Prevent Patient Falls
December 18, 2024
Dykes PC, Sousane Z, Mossburg SE. In Conversation with Patricia Dykes about The Ongoing Journey to
Prevent Patient Falls. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-patricia-dykes-a…
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psnet.ahrq.gov/node/60611/psn-pdf
June 24, 2020 - Direct Oral Anticoagulants are High-Risk Medications with
Potentially Complex Dosing
June 24, 2020
Giannini J, Wong M, Dager W, et al. Direct Oral Anticoagulants are High-Risk Medications with Potentially
Complex Dosing. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk…
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psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
February 26, 2020 - Delayed Evaluation of Abdominal Pain in an Elderly Patient.
Citation Text:
Klimkiv L, Utter GH, Barnes DK. Delayed Evaluation of Abdominal Pain in an Elderly Patient.. 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/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
September 27, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up
Citation Text:
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - When the Meds Don’t Reach the Bed
Citation Text:
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
May 01, 2018 - In Conversation with…David W. Bates, MD, MSc
May 1, 2008
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Citation Text:
In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008…
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - Errors and Near Misses: What Health Care Could Learn From Aviation
Carl Macrae, PhD | December 1, 2016
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Citation Text:
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation…
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psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
May 01, 2008 - Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work?
Josh Peterson, MD, MPH | May 1, 2018
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Citation Text:
Peterson JF. Integrating Multiple Medication Decision …
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psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety
Ronen Rozenblum, MD, MPH, and David Bates, MD, MS | November 1, 2017
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Citation Text:
Rozenblum R, Bates DW. The Role…
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psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE
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psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
January 01, 2024 - Spotlight
Spotlight
Do Not Miss Sepsis Needles in Viral Haystacks!
Source and Credits
• This presentation is based on the March 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: Michelle Hamline, MD, PhD, MAS and Ulfat
Shaikh, MD, M…
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psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
August 01, 2007 - The PeaceHealth Governance Journey in Support of Quality and Safety
John L. Haughom,
MD | August 1, 2007
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Citation Text:
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and …
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psnet.ahrq.gov/node/841566/psn-pdf
December 14, 2022 - In Conversation With... Dr. Michelle Schreiber on
Measuring Patient Safety
December 14, 2022
In Conversation With.. Dr. Michelle Schreiber on Measuring Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
Editor’s Note: Michelle Schr…
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
February 01, 2013 - In Conversation With… Beverley H. Johnson
February 1, 2013
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Citation Text:
In Conversation With… Beverley H. Johnson. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.…
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psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
February 01, 2007 - In Conversation with...Joseph Britto, MD
February 1, 2007
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Citation Text:
In Conversation with..Joseph Britto, MD. PSNet [internet]. 2007.In Conversation with...Joseph Britto, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research …