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421. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49762/psn-pdf
     June 01, 2016 - The Case of Mistaken Intubation June 1, 2016 Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/case-mistaken-intubation Case Objectives Appreciate that most older adults and many younger chronically ill patients have discussed or documented their preferences for l…

422. Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient. | PSNet
     psnet.ahrq.gov/issue/taking-charge-your-healthcare-your-path-being-empowered-patient
     May 24, 2017 - Toolkit Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient. Citation Text: Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient. Chicago, IL: Consumers Advancing Patient Safety; 2009. Copy Citation Save Save to your libr…

423. Improving team information sharing with a structured call-out in anaesthetic emergencies: a randomized controlled trial. | PSNet
     psnet.ahrq.gov/issue/improving-team-information-sharing-structured-call-out-anaesthetic-emergencies-randomized
     November 17, 2014 - Study Improving team information sharing with a structured call-out in anaesthetic emergencies: a randomized controlled trial. Citation Text: Weller JM, Torrie J, Boyd M, et al. Improving team information sharing with a structured call-out in anaesthetic emergencies: a randomized control…

424. Barriers and enablers affecting patient engagement in managing medications within specialty hospital settings. | PSNet
     psnet.ahrq.gov/issue/barriers-and-enablers-affecting-patient-engagement-managing-medications-within-specialty
     December 12, 2014 - Study Barriers and enablers affecting patient engagement in managing medications within specialty hospital settings. Citation Text: Manias E, Rixon S, Williams A, et al. Barriers and enablers affecting patient engagement in managing medications within specialty hospital settings. Health …

425. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34871/psn-pdf
     February 09, 2011 - Educational levels of hospital nurses and surgical patient mortality. February 9, 2011 Aiken LH, Clarke S, Cheung RB, et al. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290(12):1617-1623. https://psnet.ahrq.gov/issue/educational-levels-hospital-nurses-and-surgical-patient-morta…

426. Too Many Cooks Spotlight Pdf (pdf file)
     psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
     January 01, 2020 - Spotlight Too Many Cooks in the Kitchen Source and Credits • This presentation is based on the August 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Richard P. Dutton, MD, MBA o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…

427. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49743/psn-pdf
     September 01, 2015 - Dual Therapy Debacle September 1, 2015 Kayser SR. Dual Therapy Debacle. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/dual-therapy-debacle The Case An elderly man with a history of arthritis, benign prostatic hypertrophy with urinary obstruction, hyperlipidemia, obesity, and a long history of tobacco use …

428. Economic evaluation of the impact of medication errors reported by US clinical pharmacists. | PSNet
     psnet.ahrq.gov/issue/economic-evaluation-impact-medication-errors-reported-us-clinical-pharmacists
     February 02, 2011 - Organizational culture: an important context for addressing and improving hospital to community patient … discharge.

429. Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
     January 01, 2020 - Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx Spotlight Code Status vs. Care Status Source and Credits • This presentation is based on the December 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Rebe…

430. Medication Reconciliation: Whose Job Is It? | PSNet
     psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
     May 01, 2018 - SPOTLIGHT CASE Medication Reconciliation: Whose Job Is It? Citation Text: Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Googl…

431. Good for You, Good for Us, Good for Everybody. | PSNet
     psnet.ahrq.gov/issue/good-you-good-us-good-everybody
     October 20, 2021 - Book/Report Good for You, Good for Us, Good for Everybody. Citation Text: Good for You, Good for Us, Good for Everybody. Ridge K. London, England: Crown Copyright; 2021. September 22, 2021. Copy Citation Save Save to your library Print Download PDF …

432. DRESSed for Failure | PSNet
     psnet.ahrq.gov/web-mm/dressed-failure
     September 01, 2011 - DRESSed for Failure Citation Text: Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

433. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-469
     December 31, 2024 - January 8, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports…

434. Communication factors in the follow-up of abnormal mammograms. | PSNet
     psnet.ahrq.gov/issue/communication-factors-follow-abnormal-mammograms
     March 02, 2011 - Study Communication factors in the follow-up of abnormal mammograms. Citation Text: Poon EG, Haas JS, Puopolo AL, et al. Communication factors in the follow-up of abnormal mammograms. J Gen Intern Care. 2004;19(4):316-323. doi:10.1111/j.1525-1497.2004.30357.x. Copy Citation Forma…

435. Improvement in patient safety may precede policy changes: trends in patient safety indicators in the United States, 2000-2013. | PSNet
     psnet.ahrq.gov/issue/improvement-patient-safety-may-precede-policy-changes-trends-patient-safety-indicators-united
     November 01, 2017 - Study Improvement in patient safety may precede policy changes: trends in patient safety indicators in the United States, 2000-2013. Citation Text: Tedesco D, Moghavem N, Weng Y, et al. Improvement in patient safety may precede policy changes: trends in patient safety indicators in the U…

436. How Can Health Care Organizations Become More Health Literate?: Workshop Summary. | PSNet
     psnet.ahrq.gov/issue/how-can-health-care-organizations-become-more-health-literate-workshop-summary
     October 08, 2014 - Book/Report How Can Health Care Organizations Become More Health Literate?: Workshop Summary. Citation Text: How Can Health Care Organizations Become More Health Literate?: Workshop Summary. Hernandez LM; Roundtable on Health Literacy; Board on Population Health and Public Health Pra…

437. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853239/psn-pdf
     September 06, 2023 - In their own words: safety and quality perspectives from families of hospitalized children with medical complexity. September 6, 2023 Mauskar S, Ngo T, Haskell H, et al. In their own words: safety and quality perspectives from families of hospitalized children with medical complexity. J Hosp Med. 2023;18(9):777-786…

438. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49543/psn-pdf
     September 01, 2007 - Medication Reconciliation: Whose Job Is It? September 1, 2007 Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it Case Objectives Appreciate the prevalence and impact of medication discrepancies at times of transition in …

439. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations | PSNet
     psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
     October 27, 2022 - SPOTLIGHT CASE Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations Citation Text: Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. PSNet [internet]. Rockville (MD): Agency for He…

440. Failure to Latch | PSNet
     psnet.ahrq.gov/web-mm/failure-latch
     November 27, 2012 - Failure to Latch Citation Text: Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…