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psnet.ahrq.gov/node/49753/psn-pdf
February 01, 2016 - Robotic Surgery: Risks vs. Rewards
February 1, 2016
Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
Case Objectives
Discuss the background and current trends in robotic surgery.
Identify the benefits of robotic s…
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
June 28, 2023
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue
Necrosis and Cuff Rupture. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…
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psnet.ahrq.gov/node/49534/psn-pdf
May 01, 2007 - Antiseizure Medication Disorder
May 1, 2007
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
Case Objectives
Appreciate the challenges of safe use of antiepileptic medications.
Identify phenytoin toxicity.
Understand the pharmaco…
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psnet.ahrq.gov/node/49657/psn-pdf
July 01, 2012 - Not-So-Therapeutic Tap
July 1, 2012
Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
Case Objectives
Describe current issues with training clinicians to perform procedures.
Understand how simulation can be used to ensure trainees are competent in proc…
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psnet.ahrq.gov/node/49491/psn-pdf
September 01, 2005 - Time of Death?
September 1, 2005
Taekman JM, Wright MC. Time of Death? PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/time-death
The Case
An 80-year-old woman with multiple illnesses, including chronic obstructive pulmonary disease (COPD),
was found pulseless and cyanotic in her hospital bed. A code was ca…
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psnet.ahrq.gov/node/33787/psn-pdf
January 01, 2018 - In Conversation With… Maureen Bisognano
June 1, 2015
In Conversation With… Maureen Bisognano. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-maureen-bisognano
Editor's note: Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement
(IHI). We spoke with her about I…
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psnet.ahrq.gov/node/33826/psn-pdf
February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM
February 1, 2017
In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
Editor's note: Dr. Edmondson is professor of Leadership and Management at Harvard Business School.
Her la…
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - In Conversation With… Mark Chassin, MD, MPP, MPH
April 1, 2017
In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
Editor's note: Dr. Chassin is president and chief executive officer of The Joint Commission. He is also
p…
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psnet.ahrq.gov/node/33776/psn-pdf
January 01, 2015 - In Conversation With… Mark Graban, MS, MBA
January 1, 2015
In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
Editor's note: Mark Graban, MS, MBA, is an internationally recognized expert in Lean Healthcare, which
has become one of…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
December 01, 2014 - PowerPoint Presentation
Spotlight
A Stroke of Error
This presentation is based on the December 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Kevin M. Barrett, MD, MSc, Consultant, Associate Professor of Neurology, Director, Neurohospitalist F…
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psnet.ahrq.gov/node/50844/psn-pdf
January 29, 2020 - Improving Patient Safety and Team Communication
through Daily Huddles
January 29, 2020
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet].
2020.
https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
Background
Communicat…
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psnet.ahrq.gov/node/50699/psn-pdf
November 26, 2019 - Patient Safety in Frail Older Patients
November 26, 2019
Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
Background
Older patients are at a particular risk of experiencing a patient safety event. Stud…
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psnet.ahrq.gov/node/73303/psn-pdf
May 26, 2021 - Safety Culture in EMS
May 26, 2021
Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/safety-culture-ems
Defining a Just Culture
A Just Culture is one that supports transparent and honest error reporting with the goal of fostering an
environmen…
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psnet.ahrq.gov/node/33851/psn-pdf
January 01, 2017 - The Weekend Effect
January 1, 2017
Ranji SR. The Weekend Effect. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/weekend-effect
Annual Perspective 2017
Introduction
Anyone who has spent time in a hospital as a patient or staff member may recognize that the availability of
services and personnel can va…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
November 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case November 2005
Reconciling Doses
Source and Credits
This presentation is based on the November 2005 Spotlight Case in Emergency Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Frank Federico, RPh,…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - Spotlight Case July 2008
Spotlight Case
Delirium or Dementia?
Source and Credits
This presentation is based on the May 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: James L. Rudolph, MD, SM
Editor, AHRQ WebM&M: Robert Wachter, MD
Sp…
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psnet.ahrq.gov/node/33627/psn-pdf
February 01, 2006 - Removing Insult from Injury—Disclosing Adverse Events
February 1, 2006
Wu AW. Removing Insult from Injury—Disclosing Adverse Events. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
Perspective
You pull into a parking space, swing open the car door, and ar…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
December 01, 2011 - Spotlight Case July 2008
Spotlight Case
Order Interrupted by Text: Multitasking Mishap
*
*
Source and Credits
This presentation is based on the December 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John Halamka, MD, MS, Chief Informa…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - PowerPoint Presentation
Spotlight
The Hazards of Distraction: Ticking All the EHR Boxes
*
Source and Credits
This presentation is based on the February 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - Falling Through the Crack (in the Bedrails)
May 1, 2016
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
Case Objectives
Review the epidemiology of patient falls and associated injuries in the hospital set…