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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. 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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. 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,…
  16. 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…
  17. Psn-Pdf (pdf file)

    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…
  18. 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…
  19. 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…
  20. Psn-Pdf (pdf file)

    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…

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