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psnet.ahrq.gov/web-mm/cups-error
January 12, 2011 - Cups of Error
Citation Text:
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - Patient Mix-Up
Citation Text:
Shojania KG. Patient Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/web-mm/resuscitate-or-not
November 01, 2011 - To Resuscitate or Not?
Citation Text:
Wu AW, Pronovost P. To Resuscitate or Not?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/listen-family
April 15, 2015 - Listen to the Family
Citation Text:
Campbell D. Listen to the Family. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/flying-object-hits-mri
September 01, 2005 - Flying Object Hits MRI
Citation Text:
Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx
Spotlight
When the Indications for Drug
Administration Blur
Source and Credits
• This presentation is based on the June 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Julia Munsch,…
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psnet.ahrq.gov/node/36352/psn-pdf
April 14, 2011 - Patient expectations of fair complaint handling in
hospitals: empirical data.
April 14, 2011
Friele RD, Sluijs EM. Patient expectations of fair complaint handling in hospitals: empirical data. BMC
Health Serv Res. 2006;6:106.
https://psnet.ahrq.gov/issue/patient-expectations-fair-complaint-handling-hospitals-empir…
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psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - Tremendous innovation happened with good results but sometimes it would take a trial of two or three
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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - Tremendous innovation happened with good results but sometimes it would take a trial of two or three
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psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
August 01, 2018 - Why hasn't that happened?
MW : It's a function of the structure of health care.
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psnet.ahrq.gov/node/837784/psn-pdf
August 05, 2022 - In Conversation With... Francoise Marvel, MD
August 5, 2022
In Conversation With.. Francoise Marvel, MD. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-francoise-marvel-md
Editor’s note: Francoise A. Marvel, MD, is an assistant professor of medicine within the Division of
Cardiology at Joh…
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psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
December 07, 2020 - In Conversation With... Katie J. Suda, PharmD, MS
December 7, 2020
Also Read the Essay
Citation Text:
In Conversation With.. Katie J. Suda, PharmD, MS . PSNet [internet]. 2020.In Conversation With... Katie J. Suda, PharmD, MS . PSNet [internet]. Rockville (MD): …
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience
William S. Krimsky, MD | November 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [inter…
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psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
May 01, 2007 - In Conversation with...Sir Liam Donaldson, MD, MSc
May 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Sir Liam Donaldson, MD, MSc. PSNet [internet]. 2007.In Conversation with...Sir Liam Donaldson, MD, MSc. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
May 01, 2007 - Patient Safety in the United Kingdom: Evolution and Progress
Susan Burnett and Charles Vincent, PhD | May 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evol…
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psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
January 01, 2014 - Some other tangential opportunities just happened because you need to write a lot of papers early in
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psnet.ahrq.gov/node/45840/psn-pdf
February 08, 2017 - Implementation of the safety huddle.
February 8, 2017
Kylor C, Napier T, Rephann A, et al. Implementation of the Safety Huddle. Crit Care Nurse. 2016;36(6):80-
82.
https://psnet.ahrq.gov/issue/implementation-safety-huddle
The safety huddle is becoming common within health care practice as a way to inform clinician…
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psnet.ahrq.gov/web-mm/or-peeping
May 01, 2015 - OR Peeping
Citation Text:
Mackenzie CF. OR Peeping. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Dow…
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psnet.ahrq.gov/node/49604/psn-pdf
June 01, 2010 - Tacit Handover, Overt Mishap
June 1, 2010
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
The Case
A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3
years earlier to treat an abdo…
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psnet.ahrq.gov/node/50842/psn-pdf
January 29, 2020 - Patient Identification Errors: A Systems Challenge
January 29, 2020
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
The Cases
The following four events involving five patients all involved…