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psnet.ahrq.gov/web-mm/hidden-mystery
December 01, 2011 - SPOTLIGHT CASE
Hidden Mystery
Citation Text:
Brunette DD. Hidden Mystery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
March 24, 2025 - Not only do they not get it, there's a general lack of recognition that they might need it.
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - prolongation, should be monitored for closely.( 4-6,10 ) A final point to highlight in this case is the lack
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psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
June 01, 2015 - SPOTLIGHT CASE
Empiric Steroids: the Good, the Bad, and the Ugly
Citation Text:
Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/33770/psn-pdf
August 01, 2014 - RW: People talked about the lack of teams in health care as being partly we've never had the
organizational
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psnet.ahrq.gov/node/60865/psn-pdf
August 31, 2020 - I've been very fortunate to, for lack of a better
term, raise five CNOs throughout my career and I'm
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psnet.ahrq.gov/node/863308/psn-pdf
February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in
Death During Endoscopy
February 28, 2024
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
The Case
A…
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psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - There is also a lack of antigravity
power in the limbs.17 Frowning the forehead may be the patient’s
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psnet.ahrq.gov/node/49758/psn-pdf
April 01, 2016 - most common
barriers to implementation were insufficient of coordination among hospital team members, lack
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psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - We found quite a lack of concern for resident safety.
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psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - Hidden Mystery
March 1, 2005
Brunette DD. Hidden Mystery. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hidden-mystery
Case Objectives
Appreciate the challenges of caring for morbidly obese patients.
List specific interventions that can be implemented when caring for obese patients.
Develop a rational ap…
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psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - current recommendations for testing and diagnosing syphilis, faulty data
gathering as evidenced by the lack
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psnet.ahrq.gov/node/33756/psn-pdf
October 01, 2013 - The most important driver of inappropriate imaging, though, is a lack of the data about when we should
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psnet.ahrq.gov/node/33784/psn-pdf
April 01, 2015 - driven by the idea
that if you don't use a checklist then things are disorganized, and that it was the lack
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psnet.ahrq.gov/node/49765/psn-pdf
August 21, 2016 - Any of these failures can result from a loss of situational awareness, i.e., lack
of intuitive understanding
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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - SPOTLIGHT CASE
When the Lytes Go Out: A Case of Inpatient Cardiac Arrest
Citation Text:
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - SPOTLIGHT CASE
Bad Writing, Wrong Medication
Citation Text:
Devine B. Bad Writing, Wrong Medication. 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/49519/psn-pdf
September 01, 2006 - Triple Handoff
September 1, 2006
Vidyarthi A. Triple Handoff. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/triple-handoff
Case Objectives
Appreciate the prevalence of handoffs and sign out related errors.
Understand the key elements of a safe and effective written and verbal sign out.
List Kotter’s 8 st…
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psnet.ahrq.gov/node/33764/psn-pdf
April 01, 2014 - that many physical injuries are happening in the workforce, as well as psychological injury due to lack
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psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd
February 26, 2025 - and for others context can go all the way out to being everything that contributes to the success or lack