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psnet.ahrq.gov/perspective/lesson-vas-team-training-program
November 01, 2011 - Lesson from the VA's Team Training Program
Julia Neily, RN, MS, MPH; Peter D. Mills, PhD, MS; Lisa M. Mazzia, MD; and Douglas E. Paull,MD | November 1, 2011
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Neily J, Mills PD, Pa…
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psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
March 01, 2008 - In Conversation with...Bradley T. Rosen, MD, MBA
March 1, 2008
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In Conversation with..Bradley T. Rosen, MD, MBA. PSNet [internet]. 2008.In Conversation with...Bradley T. Rosen, MD, MBA. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
November 01, 2011 - In Conversation With… Eduardo Salas, PhD
November 1, 2011
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In Conversation With… Eduardo Salas, PhD . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.…
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psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
March 01, 2008 - Creation of a Medical Procedure Service to Improve Patient Safety
C. Christopher Smith, MD, and Grace C. Huang, MD | March 1, 2008
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Smith CC, CHuang G. Creation of a Medical Proced…
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psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - Patient Safety During Hospital Discharge
Katherine Liang and Eric Alper, MD | April 1, 2018
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Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. Rockville…
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psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM
April 1, 2018
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In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/perspective/conversation-dave-debronkart
June 01, 2014 - How are we going to make those decisions?
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psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
November 25, 2020 - are often unable to provide their own important medical history and ED providers have to make rapid decisions
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psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - How are we going to make those decisions?
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - 250,000 procedures performed annually in the United States and a success rate of 95% or higher. 2-6 Decisions
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psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
January 01, 2015 - The role of the leader changes from the person who has all the answers and makes all the decisions to
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psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
January 01, 2015 - The role of the leader changes from the person who has all the answers and makes all the decisions to
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary …
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psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error
Citation Text:
Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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…
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psnet.ahrq.gov/web-mm/recurrent-appendicitis
January 15, 2020 - "Recurrent" Appendicitis
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Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/60376/psn-pdf
July 30, 2020 - COVID-19: Team and Human Factors to Improve Safety
July 30, 2020
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
Background
The rapid transmission of COVID-19 has resulted in an international pandem…
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - One Bronchoscopy, Two Errors
Citation Text:
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/dropped-no
October 30, 2019 - The Dropped "No"
Citation Text:
Johnson AJ. The Dropped "No". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/73650/psn-pdf
August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with
Recurrent Pneumothorax
August 25, 2021
Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent
Pneumothorax. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…
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psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization
Citation Text:
Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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