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3721. E-prescribing: E for error? | PSNet
      psnet.ahrq.gov/web-mm/e-prescribing-e-error
      February 03, 2021 - SPOTLIGHT CASE E-prescribing: E for error? Citation Text: Ashton EW. E-prescribing: E for error?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…

3722. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety | PSNet
      psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
      December 01, 2012 - SPOTLIGHT CASE "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety Citation Text: Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…

3723. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49801/psn-pdf
      August 01, 2017 - Despite Clues, Failed to Rescue August 1, 2017 Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue Case Objectives Define failure to rescue. Identify the main contributors to failure-to-rescue events. Appreciate the ongoing areas of scien…

3724. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
      January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…

3725. Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
      January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx Spotlight A Loss of Trust and a Missed Diagnosis Source and Credits • This presentation is based on the February 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.…

3726. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33855/psn-pdf
      April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM April 1, 2018 In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and Directo…

3727. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33869/psn-pdf
      November 01, 2018 - In Conversation With… David Meltzer, MD, PhD November 1, 2018 In Conversation With… David Meltzer, MD, PhD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd Editor's note: Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medici…

3728. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49750/psn-pdf
      January 01, 2016 - A Room Without Orders January 1, 2016 Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/room-without-orders Case Objectives Review a common process for planned direct hospital admissions. Describe challenges of prioritizing day-to-day patient care activities wi…

3729. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33787/psn-pdf
      January 01, 2018 - In Conversation With… Maureen Bisognano June 1, 2015 In Conversation With… Maureen Bisognano. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-maureen-bisognano Editor's note: Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement (IHI). We spoke with her about I…

3730. But See the Patient First | PSNet
      psnet.ahrq.gov/web-mm/see-patient-first
      September 27, 2023 - But See the Patient First Citation Text: Sinigayan VR. But See the Patient First. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

3731. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49737/psn-pdf
      June 01, 2015 - Unseen Perils of Urinary Catheters June 1, 2015 Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters The Case A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…

3732. Difficult Encounters: A CMO and CNO Respond | PSNet
      psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
      March 01, 2018 - They meet several times to interview individuals who have direct knowledge of the physician's behavior … The fair hearing panel is appointed by the President of the Medical Staff and can only include individuals … Often, individuals feel that their complaints fall into a black hole, are not taken seriously, or will … I appreciate that the leadership of individuals like Dr. … professionals, but the potential impact on patient safety and staff satisfaction caused by problematic individuals

3733. How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations. | PSNet
      psnet.ahrq.gov/issue/how-guides-improving-transitions-hospital-reduce-avoidable-rehospitalizations
      November 18, 2011 - May 28, 2014 Findings and Lessons From the Improving Management of Individuals With Complex

3734. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49702/psn-pdf
      March 01, 2014 - Individuals who work within such a culture expect professional conduct and feel physically and psychologically … addition, organizations should strive to build processes for assessing the extent to which systems and/or individuals … risks overlooking important safety threats posed by underprepared, willfully negligent, or impaired individuals

3735. Nosy Business | PSNet
      psnet.ahrq.gov/web-mm/nosy-business
      March 01, 2007 - Most severe nose bleeds of this nature occur in individuals older than 50 years.( 1 ) Anatomy & Epidemiology … Neoplasm is a rare cause but should be considered in individuals with recurring bleeds from the same … Posterior bleeds are more commonly seen in older individuals, and their management is more complex, typically

3736. Video to Improve Patient Safety: Clinical and Educational Uses | PSNet
      psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
      March 01, 2004 - Organizations and individuals are increasingly embracing the use of video for learning. … Structured, routine post-action reviews, either by individuals or by teams, are also becoming more prevalent … validated assessment tools ( 3,4 ), clinical protocols, and benchmark performance data become available, individuals

3737. OR Peeping | PSNet
      psnet.ahrq.gov/web-mm/or-peeping
      May 01, 2015 - the HIPAA Privacy Rule [45 UFR Prts 160 and 164] covers protected health information (PHI), "about individuals … disclosure of PHI is only likely to be granted if it involves no more than minimal risk to the privacy of individuals … are necessary, we use camera angles and image border controls that allow us to avoid recognition of individuals

3738. The Patient Education Materials Assessment Tool (PEMAT) and User's Guide: An Instrument to Assess the Understandability and Actionability of Print and Audiovisual Patient Education Materials. | PSNet
      psnet.ahrq.gov/issue/patient-education-materials-assessment-tool-pemat-and-users-guide-instrument-assess
      December 24, 2008 - February 4, 2015 Findings and Lessons From the Improving Management of Individuals With

3739. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals. | PSNet
      psnet.ahrq.gov/issue/improving-patient-safety-systems-patients-limited-english-proficiency-guide-hospitals
      August 01, 2012 - January 21, 2015 Findings and Lessons From the Improving Management of Individuals With

3740. Peripheral vision: expertise in real world contexts. | PSNet
      psnet.ahrq.gov/issue/peripheral-vision-expertise-real-world-contexts
      April 24, 2018 - August 14, 2019 The rise of human factors: optimising performance of individuals and