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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/865884/psn-pdf
May 29, 2024 - Managing Complexity in Diagnosis: Life-threatening
Complications after Gastric Bypass Surgery.
May 29, 2024
Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass
Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-…
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
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psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
February 26, 2025 - In Conversation With… Kaveh Shojania, MD
November 1, 2015
Citation Text:
In Conversation With… Kaveh Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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For…
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psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - Delayed Breast Cancer Diagnosis: A False Sense of
Security.
December 23, 2020
Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
The Case
A 60-year-old woman was se…
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - SPOTLIGHT CASE
One Toxic Drug Is Not Like Another
Citation Text:
Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - SPOTLIGHT CASE
Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees
Citation Text:
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
January 31, 2024 - In Conversation With… John D. Birkmeyer, MD
May 1, 2015
Citation Text:
In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Fo…
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psnet.ahrq.gov/node/863649/psn-pdf
February 28, 2024 - In Conversation With...Stephen Hines, PhD and Monika
Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS
3.0
February 28, 2024
In Conversation With..Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about
TeamSTEPPS 3.0. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withstephen-…
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - One is that diagnostic errors are not quite as obvious as a fall
or a medication error.
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psnet.ahrq.gov/node/33866/psn-pdf
September 01, 2018 - But we still fall
short.
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psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
February 26, 2025 - But we still fall short.
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - Where did it fall through the cracks? That image finding wasn’t on the problem list.
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psnet.ahrq.gov/node/60066/psn-pdf
March 25, 2020 - Most fall somewhere between these extremes.
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psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
May 01, 2008 - RW: It's interesting that, if you go through that list, it seems that where things might fall apart
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psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
May 01, 2018 - RW: It's interesting that, if you go through that list, it seems that where things might fall apart
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psnet.ahrq.gov/node/74120/psn-pdf
November 30, 2021 - The patient re-presented to
the ED after a fall at home. He had been living independently.
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - (4) assist with cost issues, especially for Medicare patients whose insurance may change yearly or fall
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Blunt spinal trauma, such as a motor vehicle collision or fall,
can lead to disruption of normal anatomic
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - Most fall somewhere between these extremes.