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5521. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
      January 01, 2019 - Spotlight Spotlight "Do You Want Everything Done?": Clarifying Code Status Source and Credits • This presentation is based on the December 2019 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Karl Steinberg MD, CMD, HMDC & Thaddeus M…

5522. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33733/psn-pdf
      July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes July 1, 2012 Koppel R. Patient Safety and Health Information Technology: Learning from Our Mistakes. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes Perspe…

5523. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49490/psn-pdf
      September 01, 2005 - The Wrong Channel September 1, 2005 Gosbee JW. The Wrong Channel . PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/wrong-channel The Case A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial dosing started at 50 mL/hour using a multi-channel medication pump…

5524. Is the "Surgical Personality" a Threat to Patient Safety? | PSNet
      psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
      February 24, 2021 - SPOTLIGHT CASE Is the "Surgical Personality" a Threat to Patient Safety? Citation Text: Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citati…

5525. Delayed Diagnosis of Kidney Transplant Complications | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
      January 29, 2020 - Delayed Diagnosis of Kidney Transplant Complications Citation Text: Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Goo…

5526. Deciphering the Code | PSNet
      psnet.ahrq.gov/web-mm/deciphering-code
      November 16, 2022 - Deciphering the Code Citation Text: Goldstein MK. Deciphering the Code. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…

5527. A Mid-Summer Fog | PSNet
      psnet.ahrq.gov/web-mm/mid-summer-fog
      September 29, 2017 - A Mid-Summer Fog Citation Text: Braddock CH. A Mid-Summer Fog. 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 tagged PubMedId RIS …

5528. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. | PSNet
      psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
      July 02, 2011 - Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. Citation Text: DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…

5529. Undiagnosed Vaginal Bleeding | PSNet
      psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
      July 06, 2022 - Undiagnosed Vaginal Bleeding Citation Text: Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…

5530. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50930/psn-pdf
      February 21, 2020 - Pharmacist Role in Patient Safety February 21, 2020 Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/pharmacist-role-patient-safety Background: The Evolving Role of the Pharmacist Medication errors are highly pervasive across all settings of care,[1] w…

5531. Say It Again | PSNet
      psnet.ahrq.gov/web-mm/say-it-again
      January 31, 2020 - Say It Again Citation Text: Henriksen K, Hall KK. Say It Again. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

5532. Inpatient Transitions of Care: Challenges and Safety Practices | PSNet
      psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
      June 15, 2024 - Inpatient Transitions of Care: Challenges and Safety Practices Citation Text: Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation …

5533. Discharge Planning and Transitions of Care | PSNet
      psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
      June 15, 2024 - Discharge Planning and Transitions of Care Citation Text: Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibT…

5534. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences | PSNet
      psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
      December 18, 2019 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences Citation Text: Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…

5535. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49529/psn-pdf
      February 01, 2007 - Crossed Coverage February 1, 2007 Kayser SR. Crossed Coverage. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/crossed-coverage The Case A 27-year-old woman with a history of congenital heart disease was admitted for cardiac transplantation evaluation. She had already undergone multiple surgeries, including…

5536. New Patient Mistakenly Checked in as Another | PSNet
      psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
      October 01, 2013 - New Patient Mistakenly Checked in as Another Citation Text: Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar B…

5537. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866216/psn-pdf
      July 10, 2024 - Health Plan Patient Safety Initiatives July 10, 2024 Helwig A, Sousane Z, Mossburg S. Health Plan Patient Safety Initiatives. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives When we think of improving patient safety, we often think of strategies that can be implemen…

5538. A Costly Colonoscopy Leads to a Delay in Diagnosis | PSNet
      psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
      September 01, 2014 - A Costly Colonoscopy Leads to a Delay in Diagnosis Citation Text: Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar…

5539. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49495/psn-pdf
      December 01, 2005 - Low on the Totem Pole December 1, 2005 Wachter R. Low on the Totem Pole. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/low-totem-pole Case Objectives Understand the concept of authority gradient List steps that can be taken to increase communication across an authority gradient Consider the current cultu…

5540. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital | PSNet
      psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
      May 16, 2022 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital Citation Text: Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…