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psnet.ahrq.gov/node/33726/psn-pdf
March 01, 2012 - financial risk and exposure of financial consequences to an insurance
company rendered this a business decision
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psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
April 01, 2010 - assess the impact of health care on patient functioning, and very few measures of patient engagement in decision
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psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - major opportunities for reinforcing compliance, providing information at the point of care, providing decision
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psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - Human factors engineering: a tool for medical device evaluation in hospital procurement decision-making
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - Human factors engineering: a tool for medical device evaluation in hospital procurement decision-making
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - RW : One of the big policy interventions recently has been Medicare's decision, now being followed by
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - patients and even clinicians, who might be operating in a busy environment where second guessing every decision
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psnet.ahrq.gov/node/855058/psn-pdf
October 31, 2023 - It is one of those things that can tip people over in their decision to leave a
unit, leave an organization
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psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
April 01, 2010 - assess the impact of health care on patient functioning, and very few measures of patient engagement in decision
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
March 27, 2024 - The full panoply of possible decision support opportunities have not materialized despite the fact that
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psnet.ahrq.gov/perspective/what-makes-good-checklist
October 01, 2010 - I have to make a decision.
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psnet.ahrq.gov/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
May 26, 2021 - relationship with a primary care provider can help in improving access, assessments, and accuracy of decision
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psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
September 01, 2012 - To better inform decision making on health workforce policy, a priority of the Center is to develop and
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psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
March 01, 2014 - major opportunities for reinforcing compliance, providing information at the point of care, providing decision
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - I have to make a decision.
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - To better inform decision making on health workforce policy, a priority of the Center is to develop and
-
psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Despite Clues, Failed to Rescue
August 1, 2017
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
Case Objectives
Define failure to rescue.
Identify the main contributors to failure-to-rescue events.
Appreciate the ongoing areas of scien…
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - SPOTLIGHT CASE
Multifactorial Medication Mishap
Citation Text:
Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNot…
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
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psnet.ahrq.gov/node/861738/psn-pdf
January 31, 2024 - A Laceration that Needed a Proper Exam, Not an X-Ray
January 31, 2024
Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
Disclosure of Relevant Financial Relationships: As a provider accredited by t…