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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…
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psnet.ahrq.gov/node/74149/psn-pdf
January 07, 2022 - Multiple Missed Opportunities for Suicide Risk
Assessment in Emergency and Primary Care Settings
January 7, 2022
Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and
Primary Care Settings. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/multiple-missed-opportu…
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only
Spotlight
Delay in Appropriate Diagnosis and
Treatment Leading to Death from
Pulmonary Embolism
Source and Credits
• This presentation is based on the February 2021 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - SPOTLIGHT CASE
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
Citation Text:
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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www.ahrq.gov/sites/default/files/2025-02/poghosyan-report.pdf
January 01, 2025 - Final Progress Report: Further Psychometric Testing and Validation of the Errors of Care Omission Survey (ECOS)
Further Psychometric Testing and Validation of the Errors of Care Omission Survey (ECOS)
Principal Investigator: Lusine Poghosyan, PhD, MPH, RN, FAAN,
Columbia University School of Nursing
Elaine M. Fle…
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - The Safety of Medical Devices
Christopher Nemeth, PhD | June 1, 2011
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…
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psnet.ahrq.gov/node/841467/psn-pdf
December 14, 2022 - A framework for assessing reasoning about controversial
end-of-life clinical decisions.
December 14, 2022
Fedyk M, Fairman N, Romano PS, et al. A framework for assessing reasoning about controversial end-of-
life clinical decisions. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/framework-assessing-reasonin…
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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…
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psnet.ahrq.gov/node/836976/psn-pdf
April 27, 2022 - Intraosseous Line Extravasation in a Pediatric Trauma
Patient
April 27, 2022
Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/node/60066/psn-pdf
March 25, 2020 - Some Patients Can't Wait: Improving Timeliness of
Emergency Department Care
March 25, 2020
Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
D…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight03.pdf
September 08, 2015 - The CHIPRA Quality
Demonstration Grant Program
In February 2010, the Centers for Medicare &
Medicaid Services (CMS) awarded 10 grants,
funding 18 States, to improve the quality of
health care for children enrolled in Medicaid
and the Children’s Health Insurance Program
(CHIP). Funded by the Children’s Health
I…
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psnet.ahrq.gov/node/864867/psn-pdf
April 10, 2024 - Hindsight is 20/20: Thrombolytics for Alcohol Intoxication
April 10, 2024
Hindsight is 20/20: Thrombolytics for Alcohol Intoxication. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
Disclosure of Relevant Financial Relationships: As a provider accredited by th…
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psnet.ahrq.gov/node/853902/psn-pdf
September 27, 2023 - A Missed Bowel Perforation - the Importance of
Diagnostic Reasoning
September 27, 2023
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
Disclosure of …
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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 …
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/tool-safe-oxytocin.html
July 01, 2023 - Safe Medication Administration: Oxytocin
AHRQ Safety Program for Perinatal Care
Purpose of the tool: This tool describes the key perinatal safety elements with examples for the safe administration of oxytocin during labor. The key elements are presented within the framework of the Comprehensive U…
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA
May 1, 2009
Also Read an Essay
Citation Text:
In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/node/843234/psn-pdf
January 01, 2013 - Overdose of Gabapentin and Oxycodone in a Patient with
End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts.
February 1, 2023
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with
End-Stage Renal Disease: A Case for Appropriate Interruptive D…
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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…
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - SPOTLIGHT CASE
A Stroke of Error
Citation Text:
Barrett KM. A Stroke of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-250-cannabis-evidence-summary-2022-update_0.pdf
January 01, 2022 - Evidence Summary_Comparative Effectiveness Review No. 250_Living Systematic Review on Cannabis and Other Plant-Based Treatments for Chronic Pain: 2022 Update
Comparative Effectiveness Review
Number 250
Living Systematic Review on Cannabis and
Other Plant-Based Treatments for Chronic
Pain: 2022 Update
Evide…