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psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - SPOTLIGHT CASE
Engaging Seriously Ill Older Patients in Advance Care Planning
Citation Text:
Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. …
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psnet.ahrq.gov/node/850675/psn-pdf
June 14, 2023 - Patient and Family Roles in Safety
June 14, 2023
Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety
Moving From Engagement to Partnership
Involving patients and families in healthcare decisions about patient c…
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psnet.ahrq.gov/node/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote…
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psnet.ahrq.gov/node/33769/psn-pdf
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things
Changed?
June 1, 2014
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
Perspective
In 1981, a cancer patient named Paula Carroll founded…
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psnet.ahrq.gov/node/49600/psn-pdf
April 01, 2010 - Bad Writing, Wrong Medication
April 1, 2010
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
Case Objectives
Differentiate between a medication error and an adverse drug event.
Appreciate the system complexities involved in medication erro…
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - SPOTLIGHT CASE
Harm From Alarm Fatigue
Citation Text:
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 X…
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - The "Customer" Is Always Right
February 1, 2007
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/customer-always-right
Case Objectives
Understand the importance of identifying a patient's agenda.
Appreciate the factors that contribute to unmet patient expectations.
…
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous
Combination
April 24, 2024
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous
Combination. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
The Case
A 26-ye…
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - When boundaries defining clinical responsibility blur, communication can fail (organizational).
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - EMS Patient Safety in the Field
July 28, 2021
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Augustine JJ, Fitall E, Hall KK, et al. EMS Patient Safety in the Field. PSNet [internet]. Rockville (MD): Agency for Healthcare Re…
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psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
June 01, 2016 - The recent work of the Lucian Leape Institute in defining that has been very helpful.
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psnet.ahrq.gov/perspective/conversation-cindy-brach
December 27, 2019 - Mental health was actually a trailblazer for defining cultural competence and I wrote a bit on the subject
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psnet.ahrq.gov/issue/framework-classifying-patient-safety-practices-results-expert-consensus-process
September 20, 2011 - Study
A framework for classifying patient safety practices: results from an expert consensus process.
Citation Text:
Dy SM, Taylor SL, Carr LH, et al. A framework for classifying patient safety practices: results from an expert consensus process. BMJ Qual Saf. 2011;20(7):618-24. doi:10…
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psnet.ahrq.gov/issue/why-do-hundreds-us-women-die-annually-childbirth
June 14, 2019 - Commentary
Why do hundreds of US women die annually in childbirth?
Citation Text:
Slomski A. Why Do Hundreds of US Women Die Annually in Childbirth? JAMA. 2019;321(13):1239-1241. doi:10.1001/jama.2019.0714.
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DOI Google Scholar PubMed BibTeX EndNote X3 X…
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psnet.ahrq.gov/issue/association-emotional-intelligence-malpractice-claims-review
August 02, 2015 - Review
Association of emotional intelligence with malpractice claims: a review.
Citation Text:
Shouhed D, Beni C, Manguso N, et al. Association of Emotional Intelligence With Malpractice Claims: A Review. JAMA Surg. 2019;154(3):250-256. doi:10.1001/jamasurg.2018.5065.
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…
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psnet.ahrq.gov/issue/addressing-delays-medication-administration-patients-transferred-hospital-nursing-home-pilot
November 16, 2022 - Study
Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project.
Citation Text:
Ward KT, Bates-Jensen B, Eslami MS, et al. Addressing delays in medication administration for patients transferred …
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psnet.ahrq.gov/issue/thinking-doctor-clinical-decision-making-contemporary-medicine
October 07, 2015 - Commentary
The thinking doctor: clinical decision making in contemporary medicine.
Citation Text:
Trimble M, Hamilton P. The thinking doctor: clinical decision making in contemporary medicine. Clin Med (Lond). 2016;16(4):343-346. doi:10.7861/clinmedicine.16-4-343.
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For…
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psnet.ahrq.gov/issue/markers-enhancing-team-cognition-complex-environments-power-team-performance-diagnosis
August 30, 2006 - Review
Markers for enhancing team cognition in complex environments: the power of team performance diagnosis.
Citation Text:
Salas E, Rosen MA, Burke S, et al. Markers for enhancing team cognition in complex environments: the power of team performance diagnosis. Aviat Space Environ Med…