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psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
November 01, 2017 - August 3, 2022
Evaluating the impact of radio frequency identification retained surgical
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psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
January 01, 2016 - Some experts have criticized the practice of evaluating errors in hindsight, but we maintain that systematic
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - before any adverse effect occurred.( 19 ) When not automated, a second pharmacist should be involved in evaluating
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psnet.ahrq.gov/node/866261/psn-pdf
July 10, 2024 - rule out compartment
syndrome, as these surgeons have experience measuring compartment pressures and evaluating
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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - The Safety and Quality of Long Term Care
September 1, 2011
Evaluating
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - of these factors can result in under-treatment of pain in this patient population.( 5 ) When evaluating
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psnet.ahrq.gov/node/33826/psn-pdf
February 01, 2017 - help make sure those roles are doing what they're supposed
to be doing by giving them feedback and evaluating
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - Our mission today is to improve quality
for the public by evaluating health care organizations and inspiring
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psnet.ahrq.gov/node/72614/psn-pdf
March 01, 2021 - These improvements are consistent with both RCTs and case control studies conducted worldwide
evaluating
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - The commentary highlights the importance of evaluating patient risk of wound infection and poor wound
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psnet.ahrq.gov/web-mm/managing-care-challenges-group-home-setting-staffing-adequate-unplanned-incidents
April 27, 2022 - Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?
Citation Text:
Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/node/72618/psn-pdf
December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral
Changes Towards Medical Decisions that Improve Care
Value and Quality of Care
December 23, 2020
https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-
medical-decisions
Summary
Nudges are a change in the way choices ar…
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psnet.ahrq.gov/web-mm/over-counter-oversight
March 21, 2009 - Over-the-Counter Oversight
Citation Text:
Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX EndNote X3 XML End…
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psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
April 24, 2018 - The Fluidity of Diagnostic "Wet Reads"
Citation Text:
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Google Scholar BibTeX EndNote X3 …
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psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
May 01, 2017 - Wrong Turn through Colon: Misplaced PEG
Citation Text:
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
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psnet.ahrq.gov/web-mm/inflicting-confusion
August 04, 2021 - Inflicting Confusion
Citation Text:
Scott FI, Lichtenstein GR. Inflicting Confusion. 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 Endnote …
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - Medical Devices in the "Wild"
Citation Text:
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/node/49677/psn-pdf
February 01, 2013 - CVC Placement: Speak Now or Do Not Use the Line
February 1, 2013
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
The Case
A 48-year-old woman with a history of hypertension, psychiatric illness, and a…
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by:…
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - Failed Interpretation of Screening Tool: Delayed
Treatment
September 1, 2017
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
The Case
An 88-year-old man present…