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8701. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression | PSNet
      psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
      May 26, 2021 - SPOTLIGHT CASE Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression Citation Text: Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…

8702. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837913/psn-pdf
      August 31, 2022 - Miscommunication During the Interhospital Transport of a Critically Ill Child August 31, 2022 Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-c…

8703. Patient Safety: A Perspective from Office Practice | PSNet
      psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
      May 01, 2009 - Patient Safety: A Perspective from Office Practice Richard J. Baron, MD | May 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Baron RJ. Patient Safety: A Perspective from Office Practice. PSNet [internet]. Rockville (MD…

8704. Human Factors Engineering Can Teach You How to Be Surprised Again | PSNet
      psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
      November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again John Gosbee, MD, MS | November 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Aga…

8705. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74120/psn-pdf
      November 30, 2021 - Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care November 30, 2021 Spero H, Usher AE, Howard B, et al. Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care . PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/culture-clash-no-mo…

8706. In Conversation With… John Halamka, MD, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
      March 27, 2024 - In Conversation With… John Halamka, MD, MS May 1, 2018  Citation Text: In Conversation With… John Halamka, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Form…

8707. Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up | PSNet
      psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
      September 27, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up Citation Text: Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…

8708. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations | PSNet
      psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
      September 27, 2023 - SPOTLIGHT CASE Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations Citation Text: Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

8709. Build Culture of IBH by Obtaining Expertise | The Academy
      integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/obtain-behavioral-health-expertise-and-build-culture-integration
      September 01, 2025 - An official website of the Department of Health & Human Services Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates The Academy Integrating Behavioral Health & Primary Care Expand Navi…

8710. New Models of Primary Care Workforce and Financing - Case Example #7: Cherokee Health Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_7.pdf
      October 01, 2016 - New Models of Primary Care Workforce and Financing - Case Example #7: Cherokee Health Systems New Models of Primary Care Workforce and Financing Case Example Cherokee Health Systems 7 New Models of Primary Care Workforce and Financing Case Example #7: Cherokee Health Systems …

8711. Coaching (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_6-coaching-speaker-notes.pdf
      July 01, 2023 - Coaching Hospital AIM Team Leads SPPC‐II Coaching Module 6 of 8 SPPC‐II Toolkit SCRIPT Welcome to Module 6 of the SPPC‐II Teamwork Toolkit. In this module, we’ll learn some tactics for coaching your frontline providers on using the teamwork tools. 1 Hospital AIM Team Leads SPPC‐II Coaching …

8712. Introduction _x000b_to the SPPC-II Teamwork Toolkit _x000b_for Obstetric Hemorrhage - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_1-introduction.pptx
      July 01, 2023 - Introduction _x000b_to the SPPC-II Teamwork Toolkit _x000b_for Obstetric Hemorrhage - PowerPoint Presentation SPPC-II Toolkit Introduction to the SPPC-II Teamwork Toolkit for Obstetric Hemorrhage Module 1 of 8 AHRQ Pub. No. 23-0046 July 2023 Hospital AIM Team Leads SPPC-II SCRIPT Thank you for participating in …

8713. National Action Alliance to Advance Patient Safety Webinar Series (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/CMS-Aug-23-board-session.pdf
      August 22, 2023 - National Action Alliance to Advance Patient Safety Webinar Series National Action Alliance to Advance Patient Safety Webinar Series Engaging Boards and Executive Leadership In Safety August 22, 2023 Beth Daley Ullem Founder and CEO, Quality and Safety First National Action Alliance To Advance …

8714. Coaching (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_6-coaching-speaker-notes.pdf
      July 01, 2023 - Coaching Hospital AIM Team Leads SPPC‐II Coaching Module 6 of 8 SPPC‐II Toolkit SCRIPT Welcome to Module 6 of the SPPC‐II Teamwork Toolkit. In this module, we’ll learn some tactics for coaching your frontline providers on using the teamwork tools. 1 Hospital AIM Team Leads SPPC‐II Coaching …

8715. In Conversation with...Peter J. Pronovost, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
      October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD October 1, 2010  Also Read an Essay Citation Text: In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010.In Conversation with...Peter J. Pronovost, MD, PhD. PSNet [internet]. Rockville (MD): Ag…

8716. In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges | PSNet
      psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
      April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT | April 24, 2024  Also Read the Essay View more articles from the same authors. Citation Text: Leary KB. In Con…

8717. The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance | PSNet
      psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
      April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance Lance L. Roberts, MS; Marcia M. Ward, PhD; Thomas C. Evans, MD | April 1, 2010  Also Read a Conversation View more articles from the same authors. …

8718. Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-psychological-safety.pdf
      September 01, 2023 - Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error Issue Brief 15 Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error PATIENT SAFETY e This page intentionally left blank. e Issue Brief 15 Strategies for I…

8719. Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work? | PSNet
      psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
      May 01, 2008 - Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work? Josh Peterson, MD, MPH | May 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Peterson JF. Integrating Multiple Medication Decision …

8720. What Makes a Good Checklist | PSNet
      psnet.ahrq.gov/perspective/what-makes-good-checklist
      October 01, 2010 - What Makes a Good Checklist Anne Collins McLaughlin, PhD | October 1, 2010  Also Read a Conversation View more articles from the same authors. Citation Text: McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…