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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx
Spotlight
The Risks of a Malpositioned Gastrostomy Tube and
Poor Communication
Source and Credits
• This presentation is based on the November 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahr…
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psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
January 01, 2008 - Implementing a Patient Safety Program at a Large National Health System
Loran Hauck, MD, and Jan Jacob, MBA, RN | January 1, 2008
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Hauck LD, Jacob J. Implementing a Patient Safety …
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - SPOTLIGHT CASE
An Inadvertent Bolus of Norepinephrine.
Citation Text:
Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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F…
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - EMS Patient Safety in the Field
July 28, 2021
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Augustine JJ, Fitall E, Hall KK, et al. EMS Patient Safety in the Field. PSNet [internet]. Rockville (MD): Agency for Healthcare Re…
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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/node/73334/psn-pdf
August 01, 2024 - An Inadvertent Bolus of Norepinephrine.
May 26, 2021
Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counc…
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis
Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025
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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Savitz LA, S…
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Savitz LA, Sousane Z, Mossburg SE. Learning …
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - The Evolution of Root Cause Analysis
Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025
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Behrhorst J, Gale B, Van CM. Th…
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psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
December 18, 2024 - The Ongoing Journey to Prevent Patient Falls
Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD | December 18, 2024
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Dykes PC, Sousane Z, Mossb…
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psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls
Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD | December 18, 2024
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psnet.ahrq.gov/perspective/conversation-elizabeth-salisbury-afshar-about-harm-reduction-strategies-improve-safety
October 30, 2024 - In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd | October 30, 2024
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psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-who-use-substances
October 30, 2024 - Harm Reduction Strategies to Improve Safety for People Who Use Substances
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd | October 30, 2024
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Salisbury-…