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361. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis | PSNet
     psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
     January 13, 2010 - SPOTLIGHT CASE A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis Citation Text: Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…

362. A Laceration that Needed a Proper Exam, Not an X-Ray | PSNet
     psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
     November 25, 2020 - SPOTLIGHT CASE A Laceration that Needed a Proper Exam, Not an X-Ray Citation Text: Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Cit…

363. In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring | PSNet
     psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
     April 26, 2023 - In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring April 26, 2023  Also Read the Essay Citation Text: In Conversation with.. Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring. PSNet [internet]. 2023.In…

364. A Loss of Trust and a Missed Diagnosis | PSNet
     psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
     October 31, 2023 - SPOTLIGHT CASE A Loss of Trust and a Missed Diagnosis Citation Text: Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format:…

365. New Insights About Team Training From a Decade of TeamSTEPPS | PSNet
     psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
     February 01, 2017 - New Insights About Team Training From a Decade of TeamSTEPPS David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS | February 1, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Baker DP, King HB, Battles J. New Ins…

366. The Comprehensivist Model of Care: A Hospitalist's View | PSNet
     psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
     November 01, 2018 - The Comprehensivist Model of Care: A Hospitalist's View Robert Wachter, MD | November 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Wachter R. The Comprehensivist Model of Care: A Hospitalist's View. PSNet [internet].…

367. What Happened on Telemetry? | PSNet
     psnet.ahrq.gov/web-mm/what-happened-telemetry
     January 18, 2012 - SPOTLIGHT CASE What Happened on Telemetry? Citation Text: Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNo…

368. Multiple Levels Involved in Prescribing the Wrong Medication | PSNet
     psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
     December 23, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication Citation Text: Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Cit…

369. An Inadvertent Bolus of Norepinephrine. | PSNet
     psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
     December 04, 2016 - SPOTLIGHT CASE An Inadvertent Bolus of Norepinephrine. Citation Text: Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation F…

370. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units | PSNet
     psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
     April 26, 2023 - Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units Susan McGrath, PhD,George Blike, MD, MHCDS,Bryan M. Gale, MA,Sarah E. Mossburg, RN, PhD | April 26, 2023  Also Read the Conversation View more articles from the same authors. Citation…

371. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? | PSNet
     psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
     March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? Ian Scott, MBBS, MHA, MEd | March 1, 2015  Also Read a Conversation View more articles from the same authors. Citation Text: Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety …

372. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism | PSNet
     psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
     December 31, 2024 - SPOTLIGHT CASE Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism Citation Text: McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…

373. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety | PSNet
     psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
     March 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety Sara J. Singer, MBA, PhD | March 1, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Singer SJ. Our Maturing Understanding of Safety C…

374. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please | PSNet
     psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
     September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please Teryl K. Nuckols, MD, MSHS | September 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Nuckols TK. Incident Reporting: More Attention to the …