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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
January 01, 2024 - Spotlight
Spotlight
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
1
Source and Credits
This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Garth Utter, MD, MSc, FACS…
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psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…
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psnet.ahrq.gov/node/38151/psn-pdf
March 18, 2010 - Medication errors associated with documented allergies.
March 18, 2010
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
https://psnet.ahrq.gov/issue/medication-errors-associated-documented-allergies
This article analyzed reports of medication errors due to patient allergies and found that lack of patient o…
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psnet.ahrq.gov/issue/documenting-day-discussion-ahead-crest-wave-creating-national-agenda-systemic-change-enhanced
April 28, 2021 - Book/Report
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change for Enhanced Clinician Well-Being.
Citation Text:
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change …
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psnet.ahrq.gov/node/49790/psn-pdf
April 01, 2017 - Patient Allergies and Electronic Health Records
April 1, 2017
Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
The Case
A 40-year-old woman presented with recurring intense right upper quadrant pain, whi…
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psnet.ahrq.gov/node/37952/psn-pdf
July 30, 2008 - Documentation bad habits: shortcuts in electronic
records pose risk.
July 30, 2008
Dimick C. J AHIMA. 2008;79(6):40-43; quiz 45-46.
https://psnet.ahrq.gov/issue/documentation-bad-habits-shortcuts-electronic-records-pose-risk
This article addresses problems that can arise when clinicians use "copy and paste" to pop…
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psnet.ahrq.gov/node/45775/psn-pdf
March 20, 2017 - A patient feedback reporting tool for OpenNotes:
implications for patient–clinician safety and quality
partnerships.
March 20, 2017
Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-
clinician safety and quality partnerships. BMJ Qual Saf. 2016;26(4):312-3…
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psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - The (dis)utility of these specific documents has been previously discussed.
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psnet.ahrq.gov/issue/challenges-nurses-efforts-retrieving-documenting-and-communicating-patient-care-information
November 18, 2016 - Study
Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.
Citation Text:
Keenan G, Yakel E, Lopez KD, et al. Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information. J Am Med Inform Assoc. 2013…
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psnet.ahrq.gov/issue/clarifying-adverse-drug-events-clinicians-guide-terminology-documentation-and-reporting
February 03, 2011 - Study
Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting.
Citation Text:
Nebeker JR, Barach P, Samore MH. Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting. Ann Intern Med. 2004;140(10):795-801…
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psnet.ahrq.gov/issue/perinatal-clinical-decision-support-system-documentation-tool-patient-safety
December 12, 2014 - Commentary
Perinatal clinical decision support system: a documentation tool for patient safety.
Citation Text:
Provost C, Gray M. Perinatal clinical decision support system: a documentation tool for patient safety. Nurs Womens Health. 2007;11(4):407-10.
Copy Citation
Format:
…
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psnet.ahrq.gov/node/44522/psn-pdf
June 21, 2016 - Impact of an electronic alert notification system
embedded in radiologists' workflow on closed-loop
communication of critical results: a time series analysis.
June 21, 2016
Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in
radiologists' workflow on closed-loop com…
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psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cybersecurity
March 27, 2024 - https://business.depaul.edu/academics/economics/news-and-events/Documents/Ransomware_Manuscript.pdf … https://aspr.hhs.gov/cyber/Documents/Health-Care-Sector-Cybersecurity-Dec2023-508.pdf
3.
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psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
March 27, 2024 - https://aspr.hhs.gov/cyber/Documents/Health-Care-Sector-Cybersecurity-Dec2023-508.pdf
3. … https://business.depaul.edu/academics/economics/news-and-events/Documents/Ransomware_Manuscript.pdf
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - Baffled by Botulinum Toxin
Citation Text:
Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/node/866995/psn-pdf
October 30, 2024 - A Cognitive and Communication Blind Spot Contributes
to Permanent Paralysis
October 30, 2024
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
Disclosur…
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psnet.ahrq.gov/issue/medication-details-documented-hospital-discharge-cross-sectional-observational-study-factors
April 24, 2018 - Study
Medication details documented on hospital discharge: cross-sectional observational study of factors associated with medication non-reconciliation.
Citation Text:
Grimes TC, Duggan CA, Delaney TP, et al. Medication details documented on hospital discharge: cross-sectional observat…
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - SPOTLIGHT CASE
When the Indications for Drug Administration Blur
Citation Text:
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citation
…
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psnet.ahrq.gov/node/37947/psn-pdf
May 04, 2010 - Computerized physician order entry of medications and
clinical decision support can improve problem list
documentation compliance.
May 4, 2010
Galanter W, Hier DB, Jao C, et al. Computerized physician order entry of medications and clinical decision
support can improve problem list documentation compliance. Int J …
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psnet.ahrq.gov/web-mm/sloppy-and-paste
February 02, 2011 - Sloppy and Paste
Citation Text:
Hirschtick RE. Sloppy and Paste. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …