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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/33637/psn-pdf
August 01, 2006 - In Conversation with...Lucian Leape, MD
August 1, 2006
In Conversation with..Lucian Leape, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: What kind of career did you fashion for yourself prior to
getting involved in safety an…
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - Continuity Errors in Resident Clinic
Citation Text:
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - SPOTLIGHT CASE
Harm From Alarm Fatigue
Citation Text:
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.
Citation Text:
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line
Citation Text:
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
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psnet.ahrq.gov/node/49669/psn-pdf
November 01, 2012 - Transfusion Overload
November 1, 2012
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfusion-overload
Case Objectives
Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit
below 30% are not supported by the evidence.…
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psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
February 01, 2010 - The Role of Graduate Medical Education (GME) in Improving Patient Safety
Arpana R. Vidyarthi, MD; Robert B. Baron, MD, MS | February 1, 2010
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Baron RB, Vidyarthi A. The Role of Gra…
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psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
May 01, 2013 - Strengthening the Business Case for Patient Safety
Peter K. Lindenauer, MD, MSc | May 1, 2013
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. …
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psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
February 01, 2010 - In Conversation with…Thomas J. Nasca, MD
February 1, 2010
Also Read an Essay
Citation Text:
In Conversation with…Thomas J. Nasca, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
…
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psnet.ahrq.gov/node/857059/psn-pdf
November 29, 2023 - The Risks of a Malpositioned Gastrostomy Tube and Poor
Communication
November 29, 2023
Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet].
2023.
https://psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
Disclosure of Relevant Financial …
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psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
June 01, 2010 - unintended consequences of poorly designed measures, as described by Wachter and colleagues. 20 Only an integrated
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psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
January 01, 2008 - developed and endorsed (at the corporate level) several significant strategic initiatives; these were integrated
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care
Source and Credits
• This presentation is based on the 2020 AHRQ WebM&M Spotlight
Case
○ See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD
○ Editor…
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psnet.ahrq.gov/node/49765/psn-pdf
August 21, 2016 - Cognitive Overload in the ICU
August 21, 2016
Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/cognitive-overload-icu
Case Objectives
Identify the role of cognitive overload—especially interruptions—in compromising quality of care and
patient safety.
List…
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psnet.ahrq.gov/node/49846/psn-pdf
November 01, 2018 - Supervision and Entrustment in Clinical Training:
Protecting Patients, Protecting Trainees
November 1, 2018
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees.
PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-pr…
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psnet.ahrq.gov/node/851870/psn-pdf
July 31, 2023 - In Conversation with... Regina Hoffman about Building
Capacity for Patient Safety
July 31, 2023
In Conversation with.. Regina Hoffman about Building Capacity for Patient Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
Editor’s no…
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psnet.ahrq.gov/node/33803/psn-pdf
January 01, 2015 - In Conversation With… Richard Kronick, PhD
February 1, 2014
In Conversation With… Richard Kronick, PhD. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
Editor's note: Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since
August 2013 …
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psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - The Wet Read
March 1, 2006
Arenson RL. The Wet Read. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/wet-read
Case Objectives
Appreciate the limitations of radiology resident emergency coverage.
Understand the rate of discrepancy between radiology resident preliminary reads and attending
radiologists' fina…