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4641. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863641/psn-pdf
      February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training February 28, 2024 Haugstetter M, Hines S, Sousane Z, et al. Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork…

4642. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
      January 01, 2021 - Spotlight Spotlight The Consequences of Miscommunication Regarding a Possible Artifact Source and Credits • This presentation is based on the June 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Kriti Gwal, MD o AHRQ WebM&M Edit…

4643. Medication Overdose | PSNet
      psnet.ahrq.gov/web-mm/medication-overdose
      September 01, 2011 - Medication Overdose Citation Text: Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

4644. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49709/psn-pdf
      May 01, 2014 - Raise the Bar May 1, 2014 Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/raise-bar The Case A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The patient was seen and evaluated by an anesthesiologist who was new to the cente…

4645. Missed TB | PSNet
      psnet.ahrq.gov/web-mm/missed-tb
      March 03, 2010 - Missed TB Citation Text: FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

4646. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841493/psn-pdf
      December 14, 2022 - Telehealth and Patient Safety. December 14, 2022 O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/telehealth-and-patient-safety Background In recent years, telehealth, or the delivery of healthcare over a distance using telecommunications techno…

4647. Is It Safe to Be Direct? | PSNet
      psnet.ahrq.gov/web-mm/it-safe-be-direct
      September 30, 2015 - Is It Safe to Be Direct? Citation Text: Kulkarni NS, Williams M. Is It Safe to Be Direct?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…

4648. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49453/psn-pdf
      July 01, 2004 - Bowel Prep July 1, 2004 Nelson D. Bowel Prep. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/bowel-prep The Case The patient is a 73-year-old woman who 20 years ago underwent treatment for breast cancer. At her daughter's suggestion, the patient requested referral for colonoscopy, as she understood there w…

4649. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33719/psn-pdf
      October 01, 2011 - The Context Is the Intervention October 1, 2011 Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/context-intervention Perspective Introduction What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this context.…

4650. Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
      January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx Spotlight When the Indications for Drug Administration Blur Source and Credits • This presentation is based on the June 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Julia Munsch,…

4651. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33694/psn-pdf
      April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA April 1, 2010 In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a priva…

4652. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49751/psn-pdf
      January 01, 2016 - New Patient Mistakenly Checked in as Another January 1, 2016 Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another The Case A 55-year-old man, presented to a primary care physician's office for an initial vis…

4653. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49430/psn-pdf
      January 01, 2004 - Triage Time Bomb January 1, 2004 Washington DL. Triage Time Bomb. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/triage-time-bomb The Case A parent presented with a child to the emergency department (ED) triage area (located around the corner and down the hall from the actual ED). The child was febrile, an…

4654. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49427/psn-pdf
      January 01, 2004 - Inadvertent Castration January 1, 2004 Calland FJ. Inadvertent Castration. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/inadvertent-castration The Case An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently increased in size. The patient described persisten…

4655. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866846/psn-pdf
      September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 24, 2024 Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/zero…

4656. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49756/psn-pdf
      April 01, 2016 - Lost in Sign Out and Documentation April 1, 2016 Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation The Case A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the emergency physician, …

4657. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49782/psn-pdf
      January 01, 2017 - A Potent Medication Administered in a Not So Viable Route January 1, 2017 Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route The Case A 55-year-old man with history of nonischemic cardiomyop…

4658. XL or Smaller? | PSNet
      psnet.ahrq.gov/web-mm/xl-or-smaller
      September 13, 2017 - XL or Smaller? Citation Text: Kozer E. XL or Smaller?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

4659. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33619/psn-pdf
      September 01, 2005 - In Conversation with…Carolyn Clancy, MD September 1, 2005 In Conversation with…Carolyn Clancy, MD. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md Editor's Note: Dr. Carolyn Clancy has been the Director of the Agency for Healthcare Research and Quality (AHRQ) since 200…

4660. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49785/psn-pdf
      February 01, 2017 - Refused Medication Error February 1, 2017 Foley M. Refused Medication Error. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/refused-medication-error The Case A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was alert to self and place only. The patient h…