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psnet.ahrq.gov/node/60856/psn-pdf
August 26, 2020 - Too Many Cooks in the Kitchen
August 26, 2020
Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for
Continuing Medical Education (ACCME), the Un…
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psnet.ahrq.gov/node/33750/psn-pdf
May 01, 2013 - In Conversation With… Ashish K. Jha, MD, MPH
May 1, 2013
In Conversation With… Ashish K. Jha, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
Editor's note: Ashish K. Jha, MD, MPH, is professor of health policy and management at the Harvard
School of Public Hea…
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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
June 01, 2003 - SPOTLIGHT CASE
Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care
Citation Text:
Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…
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psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
April 04, 2018 - SPOTLIGHT CASE
The Pains of Chronic Opioid Usage
Citation Text:
Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google S…
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - SPOTLIGHT CASE
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
Citation Text:
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - Challenges of Diabetes Management and Medication Reconciliation
Citation Text:
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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…
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psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
March 24, 2019 - Hypoxemia after Emergency Intubation
Citation Text:
Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
Google Scholar BibTeX EndNote X3 X…
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psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - The University of Texas System Clinical Safety and Effectiveness Course
Eric J. Thomas, MD, MPH; Jan Patterson, MD, MS; Sherry Martin, MEd; Doris Quinn, PhD; Gary Reed, MD; Ken Shine, MD | February 1, 2011
View more articles from the same authors.
Citation Text:
T…
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psnet.ahrq.gov/node/840256/psn-pdf
November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole
Werner, PhD
November 16, 2022
In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
Editor’s note: Dr. Pascale Carayon, PhD, is a p…
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psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
May 01, 2009 - Where do you see the translation falling short?
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - Delirium, falls, fractures, subdurals, testosterone suppression, motor vehicle collisions.
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psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
May 01, 2014 - make it problematic to generalize from the hand hygiene experience to let's say trying to decrease falls
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psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
May 22, 2017 - Delirium, falls, fractures, subdurals, testosterone suppression, motor vehicle collisions.
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psnet.ahrq.gov/node/867022/psn-pdf
October 30, 2024 - Delayed Symptomatic Subdural Hematoma Following an
Initially Normal CT Head
October 30, 2024
Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-h…
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - Spotlight
Spotlight
A Case of Mistaken Capacity: Why a
Thorough Psychosocial History Can
Improve Care
Source and Credits
• This presentation is based on the March 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: Katrina Pasao, MD…
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Intubation Mishap
September 1, 2003
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/intubation-mishap
Case Objectives
To understand and apply a structured method of human factors case analysis
To describe the key components of effective teamwork
To understand the imp…
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - Complications of ECMO During Transport
April 29, 2020
Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
The Case
A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with
acute on chro…
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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/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.
Copy Citation
Format:
Google Scholar BibTeX EndNote X…
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - A Case of Mistaken Capacity: Why A Thorough
Psychosocial History Can Improve Care.
March 31, 2022
Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve
Care. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-c…