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  1. 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…
  2. Psn-Pdf (pdf file)

    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…
  3. 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…
  4. 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…
  5. 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…
  6. 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…
  7. Psn-Pdf (pdf file)

    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…
  8. 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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Highlight03 (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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 …
  14. 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 …
  15. 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…
  16. 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. …
  17. Psn-Pdf (pdf file)

    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…
  18. 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…
  19. 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…
  20. 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…