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psnet.ahrq.gov/node/33672/psn-pdf
September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH
September 1, 2008
In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
Editor's note: Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women's
Hospital and Assi…
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psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - A Mistaken Dose of Naloxone
Citation Text:
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/50769/psn-pdf
February 15, 2017 - Cultural Competence and Patient Safety
December 27, 2019
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
Background
Culture can be defined as the “personal identification, language, thoughts, co…
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psnet.ahrq.gov/node/33622/psn-pdf
November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP
November 1, 2005
In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
Editor's Note: Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare
I…
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psnet.ahrq.gov/web-mm/dont-pick-picc
December 01, 2011 - Don't Pick the PICC
Citation Text:
McGill RL. Don't Pick the PICC. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - Lost in Sign Out and Documentation
Citation Text:
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/returning-home-safely
December 22, 2018 - Returning Home Safely
Citation Text:
Toles M. Returning Home Safely. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/other-hand
December 12, 2012 - On the Other Hand
Citation Text:
Henneman EA. On the Other Hand. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/after-visit-confusion
August 21, 2007 - After-Visit Confusion
Citation Text:
Ventres W. After-Visit Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/round-trip-service
April 26, 2023 - Round-Trip Service
Citation Text:
McGrath MH. Round-Trip Service. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - SPOTLIGHT CASE
Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump
Citation Text:
Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump . PSNet [internet]. Rockville (MD): Agency for Heal…
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psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
May 22, 2017 - It describes a database-drudging exercise at a Boston hospital that cannot possibly show the risk of
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psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
January 01, 2014 - The CLER Pathways to Excellence report describes discoveries from the first year of the program, including
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - It describes a database-drudging exercise at a Boston hospital that cannot possibly show the risk of
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - SPOTLIGHT CASE
Transfusion Thresholds in Gastrointestinal Bleeding
Citation Text:
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. 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/delay-initiating-antibiotics-results-fatal-error
August 02, 2015 - SPOTLIGHT CASE
Delay in Initiating Antibiotics Results in Fatal Error
Citation Text:
Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/autopsy-revelation
December 01, 2007 - Autopsy Revelation
Citation Text:
Shojania KG. Autopsy Revelation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/production-pressures
November 16, 2022 - Production Pressures
Citation Text:
Carayon P. Production Pressures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - SPOTLIGHT CASE
Discharged with IV antibiotics: When issues arise, who manages the complications?
Citation Text:
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Elizabeth Gould, NP-C, COR…