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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - SPOTLIGHT CASE
Too Many Cooks in the Kitchen
Citation Text:
Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/33861/psn-pdf
July 01, 2018 - In Conversation With… Gordon Schiff, MD
July 1, 2018
In Conversation With… Gordon Schiff, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
Editor's note: Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research
and Practice, Associate Pr…
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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - SPOTLIGHT CASE
A Room Without Orders
Citation Text:
Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/73906/psn-pdf
October 06, 2021 - In Conversation With….Alison Stuebe, MD, MSc and
Kristin Tully, PhD
October 6, 2021
In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
Editor’s Note: Alison Stuebe, MD, MSc, is a…
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
January 01, 2022 - Spotlight
Spotlight
Perioperative Anaphylaxis After Insertion of
a Latex Drain in a Patient with Known Latex
Allergy
Source and Credits
• This presentation is based on the August 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 K…
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psnet.ahrq.gov/node/33791/psn-pdf
September 01, 2015 - In Conversation With… Vineet Arora, MD, MAPP
September 1, 2015
In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
Editor's note: Vineet Arora, MD, MAPP, is Director of GME Clinical Learning Environment Innovation,
Associate Pr…
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psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety
Jane Ball, PhD, and Peter Griffiths, PhD | March 1, 2018
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient…
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - Artificial Intelligence and Diagnostic Errors
January 31, 2020
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Hea…
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - In Conversation With... David Gruen, MD
January 31, 2020
Also Read the Essay
Citation Text:
In Conversation With.. David Gruen, MD. PSNet [internet]. 2020.In Conversation With... David Gruen, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research an…
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psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
March 01, 2018 - In Conversation With… Linda Aiken, PhD, RN
March 1, 2018
Also Read an Essay
Citation Text:
In Conversation With… Linda Aiken, PhD, RN. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …
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psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to
Complications and Poor Follow-up
July 31, 2023
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications
and poor follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restricti…
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - Health Care Data Science for Quality Improvement and Patient Safety
Alvin Rajkomar, MD | October 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Rajkomar A. Health Care Data Science for Quality Improvement and Patient S…
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - In Conversation with…Carolyn Clancy, MD
September 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Carolyn Clancy, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
…
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - SPOTLIGHT CASE
Diagnosing HIV-It Doesn't Take a Brain Surgeon
Citation Text:
Chou R. Diagnosing HIV-It Doesn't Take a Brain Surgeon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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…
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psnet.ahrq.gov/web-mm/need-eat
February 10, 2021 - The Need to Eat
Citation Text:
Widaman AM. The Need to Eat. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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…
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psnet.ahrq.gov/node/50755/psn-pdf
December 18, 2019 - The Need to Eat
December 18, 2019
Widaman AM. The Need to Eat. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/need-eat
The Case
A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder
caused by the lack of vitamin B1 – was admitted for possible aspiration pneum…
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - Failure to Ensure Patient Safety Leads to Patient Falls in
Nursing Homes.
April 26, 2023
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
Disclosure of Relevant Financial R…
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery
Citation Text:
Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qual…
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - SPOTLIGHT CASE
Falling Through the Crack (in the Bedrails)
Citation Text:
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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F…
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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication
Citation Text:
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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