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psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
June 24, 2020 - August 26, 2020
Defining and enhancing collaboration between community pharmacists and
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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/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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Google Scholar BibTeX EndNote…
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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/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/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/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/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/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/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/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/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/infection-prevention-compendium-long-term-care-facilities
November 08, 2017 - Tools/Toolkit
Infection Prevention Compendium For Long-Term Care Facilities.
Citation Text:
Infection Prevention Compendium For Long-Term Care Facilities. Center for Healthy Aging--New York Academy of Medicine, Yale School of Nursing.
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psnet.ahrq.gov/issue/pursuit-endpoint-diagnoses-cognitive-forcing-strategy-avoid-premature-diagnostic-closure
November 02, 2022 - Commentary
Pursuit of "endpoint diagnoses" as a cognitive forcing strategy to avoid premature diagnostic closure.
Citation Text:
Kaplan HM, Birnbaum JF, Kulkarni PA. Pursuit of “endpoint diagnoses” as a cognitive forcing strategy to avoid premature diagnostic closure. Diagnosis (Berl). 2…
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psnet.ahrq.gov/issue/sixty-seconds-medical-gaslighting
October 19, 2022 - Commentary
Sixty seconds on . . . medical gaslighting.
Citation Text:
Wise J. Sixty seconds on . . . medical gaslighting. BMJ. 2022;378:o1974. doi:10.1136/bmj.o1974.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/issue/progress-made-towards-improving-opioid-safety-further-efforts-assess-progress-and-reduce-risk
May 16, 2018 - Book/Report
Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.
Citation Text:
Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed. Washington, DC: United States Gov…
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psnet.ahrq.gov/issue/how-talk-about-patient-safety
June 24, 2019 - Book/Report
How to Talk About Patient Safety.
Citation Text:
How to Talk About Patient Safety. Hendricks R, O'Neil M, Volmert A. Boston, MA: Betsy Lehman Center for Patient Safety; March 2019.
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