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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - Spotlight
Spotlight
The Consequences of Miscommunication
Regarding a Possible Artifact
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Kriti Gwal, MD
o AHRQ WebM&M Edit…
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psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
June 01, 2014 - Mixup Beyond the Medication Label
Citation Text:
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar BibTeX EndNote …
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psnet.ahrq.gov/node/49622/psn-pdf
March 01, 2011 - Dropping the Ball Despite an Integrated EMR
March 1, 2011
Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
The Case
A patient followed at a community-based clinic that is part of a large health care system with an
in…
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psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - Milliliters vs. Milligrams
December 1, 2010
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
The Case
A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His
evaluation showed acu…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/062-protocol-training-decolonization-with-chg.pptx
October 01, 2024 - Ensuring that CHG is applied to skin with a firm massage.
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www.ahrq.gov/hai/cauti-tools/ena-slides/part2a.html
October 01, 2015 - confidence in the skills and process of decision making and how they related to reducing catheter usage and ensuring
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psnet.ahrq.gov/continuing-education
February 26, 2025 - postoperative management strategies to address intraoperative durotomy and CSF leaks, and approaches to ensuring
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www.ahrq.gov/ncepcr/reports/2025-annual-report/patient-safety.html
August 01, 2025 - relationships developed in the primary care setting among clinicians, patients, and families are essential for ensuring
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cell-free-dna-executive-summary.pdf
May 01, 2025 - Research and policy will need to focus on ensuring healthcare systems work effectively
for individuals
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - provide feedback to institutions and vendors so all can learn how to improve CPOE design and usability; Ensuring
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - involve organizational health literacy strategies that will help patients to achieve health literacy: Ensuring
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - involve organizational health literacy
strategies that will help patients to achieve health literacy:
Ensuring
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psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - Special attention should be paid to ensuring that patients and caregivers understand the
active ingredients
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digital.ahrq.gov/sites/default/files/docs/page/ESTRIN_3_I.ppt
March 08, 2006 - Applying the 80/20 rule and selecting physicians and payors that represent a larger population base
Ensuring
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psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
August 15, 2017 - Implementing evidence-based protocols in the evaluation of the acute ischemic stroke patient, ensuring
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psnet.ahrq.gov/web-mm/dressed-failure
September 01, 2011 - common to all transitions include: overcoming provider and staff resistance to using a new system, ensuring
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psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - infection control and safe use of intravascular catheters.(5) The
medical director is responsible for ensuring
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psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
April 24, 2018 - An additional timeout is undertaken prior to a new team beginning ensuring effective, efficient collaboration
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effectivehealthcare.ahrq.gov/sites/default/files/ebc-webinar-slides.pptx
June 01, 2014 - Industry Standard Compliance
Experts in Evidence Based Research
Insightful Comments and Suggestions
Ensuring