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9901. In Conversation with...Bradley T. Rosen, MD, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
      March 01, 2008 - lines if a line is in place and there is a concern about a low-grade fever, or one out of four blood cultures

9902. EMS Perils from Hospital Overcrowding | PSNet
      psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
      November 25, 2020 - Fluid cultures were negative but presumed to be the same species (Methicillin Sensitive Staphylococcus

9903. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49419/psn-pdf
      October 01, 2003 - The Other Side October 1, 2003 Vincent CA. The Other Side. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/other-side Case Objectives List the factors contributing to wrong site surgery. Understand the key components of the Universal Protocol for eliminating wrong site, wrong procedure, wrong person surger…

9904. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.ppt
      February 01, 2011 - The Culture Code: An Ingenious Way to Understand Why People Around the World Live and Buy as They Do.

9905. CE/MOC Quizzes | PSNet
      psnet.ahrq.gov/cme
      February 26, 2025 - commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding and how a culture

9906. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33842/psn-pdf
      January 01, 2018 - As such, another key facet of this work is for organizational leadership to create the blame-free culture

9907. Duty to Disclose Someone Else's Error? | PSNet
      psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
      June 01, 2004 - The challenges presented in this case reflect an outdated culture surrounding disclosure. … In such a situation, should the accepting physicians share their beliefs directly with the family about

9908. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
      January 01, 2020 - Spotlight Spotlight Inpatient Stroke Management in a Patient with Type 1 Diabetes and Home Insulin Pump Source and Credits • This presentation is based on the October 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Berit B…

9909. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836850/psn-pdf
      March 31, 2022 - The report recommended transitioning to a “Just Culture” in nursing school programs. … nurses-perceived-causes-medication-administration-errors-qualitative-systematic-review https://psnet.ahrq.gov/issue/just-culture-medication-error-prevention-and-second-victim-support-better-prescription

9910. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33732/psn-pdf
      July 01, 2012 - It was not possible given our size, political culture, and political institutions.

9911. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/73848
      July 01, 2022 - model, this study also implemented a comprehensive unit-based safety program (CUSP) to improve safety culture … model, this study also implemented a comprehensive unit-based safety program (CUSP) to improve safety culture

9912. Artificial Intelligence and Patient Safety: Promise and Challenges | PSNet
      psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
      March 27, 2024 - First, we have a patient who is hypotensive, tachycardic with fever, and positive blood cultures immediately … Annual Perspective Ensuring Patient and Workforce Safety Culture

9913. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis | PSNet
      psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
      March 09, 2022 - Intraoperative cultures were negative for bacteria. … March 9, 2022 Culture change in infection control: applying psychological principles

9914. Nothing Called Small Surgery | PSNet
      psnet.ahrq.gov/web-mm/nothing-called-small-surgery
      February 01, 2023 - July 10, 2024 Family medicine presence on labor and delivery: effect on safety culture … Surgery August 28, 2024 How does robotic-assisted surgery change OR safety culture

9915. Delayed Diagnosis of Endocrinologic Emergencies | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
      November 13, 2024 - August 4, 2021 Factors determining safety culture in hospitals: a scoping review. … WebM&M Cases Delayed Recognition of a Positive Blood Culture

9916. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
      January 01, 2016 - Progress will require not only advances in the science but also changes to today's culture, which inhibits … It's my own belief that the major factor was the perception that we were doing okay in regard to diagnosis … We need to get much better feedback if we want to excel at this, and we need to create a culture where

9917. Multifactorial Medication Mishap | PSNet
      psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
      September 01, 2016 - identifying, reporting, and analyzing medication errors, all organizations should actively cultivate a culture … identifying, reporting, analyzing, and reducing the risk of medication errors • Cultivation of a just culture

9918. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49737/psn-pdf
      June 01, 2015 - focused competency-based approach to review the microbiology of CAUTI, urinalysis collection, and urine culture … As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily

9919. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49584/psn-pdf
      April 01, 2009 - Ross Koppel, PhD Principal Investigator Study of Hospital Workplace Culture and Medication Errors Center

9920. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33787/psn-pdf
      January 01, 2018 - In other words, the culture and context matter, the leaders matter, and the mechanism is the change … Hence, the theory was that if you understood your culture and you had a mechanism that you could try