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psnet.ahrq.gov/perspective/conversation-charles-ornstein
October 01, 2009 - coverage over the death of a young child, Josie King.( 8 ) On this site, leaders from Dana-Farber and Duke described
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psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
November 01, 2018 - The answer, as described by Meltzer in the interview, is that much here is new.
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psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
November 01, 2018 - The answer, as described by Meltzer in the interview, is that much here is new.
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - coverage over the death of a young child, Josie King.( 8 ) On this site, leaders from Dana-Farber and Duke described
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - Stuebe just described.
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - while performing cardiopulmonary bypass has been reported by 55.6% of 439 surveyed perfusionists, who described
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psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
April 28, 2021 - In Conversation With... José A, Morfín, MD, FASN
April 28, 2021
Also Read the Essay
Citation Text:
In Conversation With.. José A, Morfín, MD, FASN. PSNet [internet]. 2021.In Conversation With... José A, Morfín, MD, FASN. PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
January 01, 2021 - Spotlight
Spotlight
Culture Clash No More:
Integration and Coordination of Disease
Treatment and Palliative Care
Source and Credits
• This presentation is based on the November 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Han…
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psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
January 01, 2021 - Spotlight
Spotlight
An Inadvertent Bolus of Norepinephrine
Source and Credits
• This presentation is based on the May 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarina Fazio, PhD, RN, Emma Blackmon, PhD,
RN, Amy Doroy, PhD,…
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psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md
January 01, 2009 - In Conversation with…Thomas H. Gallagher, MD
January 1, 2009
Also Read an Essay
Citation Text:
In Conversation with…Thomas H. Gallagher, MD. 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/disclosure-medical-error
January 01, 2009 - Disclosure of Medical Error
Allen Kachalia, MD, JD | January 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Kachalia A. Disclosure of Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/node/837784/psn-pdf
August 05, 2022 - In Conversation With... Francoise Marvel, MD
August 5, 2022
In Conversation With.. Francoise Marvel, MD. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-francoise-marvel-md
Editor’s note: Francoise A. Marvel, MD, is an assistant professor of medicine within the Division of
Cardiology at Joh…
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psnet.ahrq.gov/perspective/conversation-cindy-brach
December 27, 2019 - In Conversation With... Cindy Brach
December 27, 2019
Also Read the Essay
Citation Text:
In Conversation With.. Cindy Brach. PSNet [internet]. 2019.In Conversation With... Cindy Brach. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/node/49764/psn-pdf
June 01, 2016 - In the scenario described
above, the referring ED physician did not appropriately communicate the specific … Consultation," to highlight the general principles to be followed by a consultant.(2) In the case described
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psnet.ahrq.gov/issue/speaking-patient-safety-and-staff-well-being-qualitative-study
November 16, 2016 - September 23, 2017
How well is quality improvement described in the perioperative care
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psnet.ahrq.gov/issue/communication-about-harm-reduction-patients-who-have-opioid-use-disorder
January 02, 2017 - June 16, 2021
How well is quality improvement described in the perioperative care literature
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psnet.ahrq.gov/node/49412/psn-pdf
September 01, 2003 - study, with 7% having the potential for
harming the patient.(4) Wrong dose errors, such as the case described … omission error may be a possible
explanation.(4)
The investigation following the suspected error described
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psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - insulin-related hypoglycemia and errors occur annually, with 30% resulting in hospital admission.( 2 ) One report described … In the case described, several factors contributed to the error at each phase of the medication-use process … orders, as seen in this case, have also been found to be higher during handoff times.( 9 ) One study described
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psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - that such errors are common, but better tracking is
needed before these rates can be more accurately described … While some legal experts may highlight the perceived risk of
full error disclosure (as described in … there
are relatively few formal support programs available for providers after errors occur.(6) As described
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psnet.ahrq.gov/node/33663/psn-pdf
September 15, 2008 - Conclusion
The path to a totally safe hospital or health system can be best described as a journey. … This report has
described steps from our particular journey at AHS. … psnet.ahrq.gov//#ref7
https://psnet.ahrq.gov//#ref8
https://psnet.ahrq.gov//#figure
This report has described