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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
January 01, 2021 - Spotlight
Spotlight
Lost in Transitions of Care: Managing an
Opioid-Dependent Patient with Frequent
Hospitalizations
Source and Credits
• This presentation is based on the September 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary …
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psnet.ahrq.gov/node/33784/psn-pdf
April 01, 2015 - In Conversation With… David Urbach, MD, MSc
April 1, 2015
In Conversation With… David Urbach, MD, MSc. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc
Editor's note: Dr. David Urbach is Professor of Surgery and Health Policy, Management, and Evaluation
at the University…
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psnet.ahrq.gov/node/49605/psn-pdf
June 01, 2010 - Acute Respiratory Arrest in Pregnancy
June 1, 2010
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
The Case
A 35-year-old woman was 38 weeks pregnant with twins (G3P2). When she developed acute onset of
shortness of breath an…
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Direct interfacing of LIS to electronic medical record with
elimination of printed reports.
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psnet.ahrq.gov/node/49864/psn-pdf
June 01, 2019 - The proceduralist logged
into the electronic health record to verify the patient information he had
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psnet.ahrq.gov/node/49816/psn-pdf
January 01, 2018 - of naltrexone in a patient on opioids can be avoided by heeding drug–drug
interaction alerts in the electronic … health record.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
December 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case December 2007
Elopement
Source and Credits
This presentation is based on the December 2007 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Debra Gerardi, RN, MPH, JD
Creighton University School of Law
Ed…
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psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
July 23, 2024 - Hospital staff should assess, based on the needs of a hospital, whether to use an electronic health record
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psnet.ahrq.gov/web-mm/surprise-wire
July 15, 2020 - May 27, 2011
The impact of prescribing safety alerts for elderly persons in an electronic … medical record: an interrupted time series evaluation.
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psnet.ahrq.gov/node/49510/psn-pdf
May 01, 2006 - Cups of Error
May 1, 2006
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/cups-error
The Case
An 87-year-old man was 5 days postoperative from a decompressive laminectomy. Although he suffered
from dementia, he remained alert and oriented with only mild short-term memory…
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psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
March 07, 2012 - August 12, 2020
Identifying electronic health record usability and safety challenges
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psnet.ahrq.gov/node/33867/psn-pdf
October 01, 2018 - In Conversation With… Michael Cohen, RPh, MS, ScD
(hon)
October 1, 2018
In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
Editor's note: Dr. Cohen is President of the Institute for Safe Medication Practice…
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psnet.ahrq.gov/periodic-issue/periodic-issue-406
August 30, 2023 - This survey of 118 nursing homes in Switzerland found that organizations employ a variety of electronic … health record (EHR)-based tools to support medication safety, such as standardized medication lists,
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psnet.ahrq.gov/information/Panel
January 01, 2018 - in health care based on a wide range of safety improvement operations experience in medical devices, electronic … health record, root cause analysis, facility design, team communication, nursing work environment, and
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psnet.ahrq.gov/node/865466/psn-pdf
March 27, 2024 - surveillance system that will screen for
negative tone and potentially stigmatizing language in the electronic … health record alongside other risk
factors for adverse birth outcomes.8
Conclusion
Equity is a patient
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psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - SPOTLIGHT CASE
Monitoring Fetal Health
Citation Text:
Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNot…
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psnet.ahrq.gov/node/49535/psn-pdf
May 01, 2007 - Production Pressures
May 1, 2007
Carayon P. Production Pressures. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/production-pressures
The Case
A 65-year-old man with bipolar disorder was scheduled for maintenance electroconvulsive therapy (ECT), a
procedure he had received dozens of times before. These pro…
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psnet.ahrq.gov/issue/understanding-and-improving-everyday-work-healthcare
May 13, 2020 - February 15, 2023
Electronic Health Record (EHR) Safety and Usability: See What We Mean
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psnet.ahrq.gov/curated-library/organizational-learning
March 10, 2025 - industries such as manufacturing, banking, and aviation—and highlights the role of mobile technologies and electronic … health records in continuously improving health care.
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psnet.ahrq.gov/node/49505/psn-pdf
March 01, 2006 - Collegiality vs. Competence
March 1, 2006
Sagin T. Collegiality vs. Competence. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/collegiality-vs-competence
The Case
A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective
repair of a 10-cm abdominal aortic aneurys…