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psnet.ahrq.gov/node/848318/psn-pdf
May 03, 2023 - Teamwork, clinical leadership skills and environmental
factors that influence missed nursing care - a qualitative
study on hospital wards.
May 3, 2023
Beiboer C, Andela R, Hafsteinsdóttir TB, et al. Teamwork, clinical leadership skills and environmental
factors that influence missed nursing care – a qualitative st…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.365_slideshow.ppt
January 01, 2016 - PowerPoint Presentation
Spotlight
A Room Without Orders
1
This presentation is based on the January 2016
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Amy Vogelsmeier, PhD, RN, Sinclair School of Nursing; and Laurel Despins, PhD, RN, Sinclair Sc…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.293_slideshow.ppt
March 01, 2013 - Spotlight Case July 2008
Spotlight Case
A Weighty Mistake
*
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Source and Credits
This presentation is based on the March 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Seth J. Bokser, MD, MPH, Associate Professor of Pediatrics & Medical…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
February 01, 2018 - PowerPoint Presentation
Spotlight
Signout Fallout
1
Source and Credits
This presentation is based on the February 2018
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - A Tale of Two Falls
Citation Text:
Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/node/867035/psn-pdf
October 30, 2024 - A Tale of Two Falls
October 30, 2024
Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/tale-two-falls
The Cases
Case #1: A 79-year-old woman with a history of impaired cognition at baseline was brought from a skilled
nursing facility to the emergency department (ED) f…
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psnet.ahrq.gov/perspective/remote-patient-monitoring
March 15, 2023 - Remote Patient Monitoring
Colton Hood, MD, MBI,Neal Sikka, MD,Cindy Manaoat Van, MHSA,Sarah E. Mossburg, RN, PhD
| March 15, 2023
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Hood C, Sikka N, Van CM, et al. Remote Patien…
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psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
March 15, 2023 - In Conversation with... Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring
March 15, 2023
Also Read the Essay
Citation Text:
In Conversation with.. Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring. PSNet [internet]. 2023.In Conve…
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psnet.ahrq.gov/node/72618/psn-pdf
December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral
Changes Towards Medical Decisions that Improve Care
Value and Quality of Care
December 23, 2020
https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-
medical-decisions
Summary
Nudges are a change in the way choices ar…
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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - The Case of Mistaken Intubation
June 1, 2016
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/case-mistaken-intubation
Case Objectives
Appreciate that most older adults and many younger chronically ill patients have discussed or
documented their preferences for l…
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psnet.ahrq.gov/node/49783/psn-pdf
February 01, 2017 - The Hazards of Distraction: Ticking All the EHR Boxes
February 1, 2017
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
Case Objectives
List the goals of having order sets in the electronic health record…
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psnet.ahrq.gov/issue/electronic-detection-delayed-test-result-follow-patients-hypothyroidism
September 27, 2017 - Study
Electronic detection of delayed test result follow-up in patients with hypothyroidism.
Citation Text:
Meyer AND, Murphy DR, Al-Mutairi A, et al. Electronic Detection of Delayed Test Result Follow-Up in Patients with Hypothyroidism. J Gen Intern Med. 2017;32(7). doi:10.1007/s11606-0…
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psnet.ahrq.gov/issue/patient-reported-approach-identify-medical-errors-and-improve-patient-safety-emergency
July 13, 2010 - Study
A patient reported approach to identify medical errors and improve patient safety in the emergency department.
Citation Text:
Glickman SW, Mehrotra A, Shea CM, et al. A Patient Reported Approach to Identify Medical Errors and Improve Patient Safety in the Emergency Department. J Pa…
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psnet.ahrq.gov/issue/mindful-workarounds-bar-code-medication-administration
July 20, 2022 - Commentary
Mindful workarounds in bar code medication administration.
Citation Text:
Lichtner V, Dowding D. Mindful workarounds in bar code medication administration. Stud Health Technol Inform. 2022;294:740-744. doi:10.3233/shti220575.
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DOI Google Scho…
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psnet.ahrq.gov/issue/improving-patient-safety-reporting-common-formats-common-data-representation-patient-safety
October 19, 2022 - Commentary
Improving patient safety reporting with the common formats: common data representation for Patient Safety Organizations.
Citation Text:
Elkin PL, Johnson HC, Callahan MR, et al. Improving patient safety reporting with the common formats: Common data representation for Patient …
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psnet.ahrq.gov/issue/many-faces-error-disclosure-common-set-elements-and-definition
December 16, 2009 - Study
Classic
The many faces of error disclosure: a common set of elements and a definition.
Citation Text:
Fein SP, Hilborne LH, Spiritus EM, et al. The many faces of error disclosure: a common set of elements and a definition. J Gen Intern Med. 2007;22(6):75…
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psnet.ahrq.gov/issue/observational-study-frequency-severity-and-etiology-failures-postoperative-care-after-major
August 11, 2010 - Study
An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery.
Citation Text:
Symons NRA, Almoudaris AM, Nagpal K, et al. An observational study of the frequency, severity, and etiology of failures in postop…
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psnet.ahrq.gov/issue/structured-handover-general-surgery-audit-current-practice
August 08, 2018 - Study
Structured handover in general surgery: an audit of current practice.
Citation Text:
Jones HG, Watt B, Lewis L, et al. Structured Handover in General Surgery: An Audit of Current Practice. J Patient Saf. 2019;15(1):7-10. doi:10.1097/PTS.0000000000000201.
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psnet.ahrq.gov/issue/exploring-potential-using-drug-indications-prevent-look-alike-and-sound-alike-drug-errors
December 18, 2019 - Study
Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors.
Citation Text:
Seoane-Vazquez E, Rodriguez-Monguio R, Alqahtani S, et al. Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors. Expe…
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psnet.ahrq.gov/issue/electronic-health-record-safety-paradox
September 01, 2021 - Commentary
Is electronic health record safety a paradox?
Citation Text:
Harrington L. Is electronic health record safety a paradox? AACN Adv Crit Care. 2021;32(4):375-380. doi:10.4037/aacnacc2021406.
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Format:
DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 X…