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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - Root Cause Analysis Gone Wrong
Citation Text:
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/code-status-confusion
September 01, 2006 - SPOTLIGHT CASE
Code Status Confusion
Citation Text:
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - Coming Undone: Failure of Closure Device
Citation Text:
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. 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/perspective/balancing-supervision-and-autonomy-ongoing-tension
February 01, 2012 - Balancing Supervision and Autonomy: An Ongoing Tension
C. Jessica Dine, MD, MA; and Jennifer S. Myers, MD | February 1, 2012
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Dine JC, Myers JS. Balancing Supervision and Autonomy:…
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psnet.ahrq.gov/perspective/conversation-chris-cebollero-bs-ccemt-p
May 26, 2021 - In Conversation With... Chris Cebollero, BS, CCEMT-P
May 26, 2021
Also Read the Essay
Citation Text:
In Conversation With.. Chris Cebollero, BS, CCEMT-P. PSNet [internet]. 2021.In Conversation With... Chris Cebollero, BS, CCEMT-P. PSNet [internet]. Rockville (MD)…
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psnet.ahrq.gov/node/74830/psn-pdf
June 01, 2022 - The Michigan Hospital Medicine Safety Consortium (HMS)
Finds Infectious Diseases (ID) Physician Approval for
Placement of Peripherally Inserted Central Catheters
(PICCs) Prevents Unnecessary PICC Use and Reduces
Complications
February 23, 2022
https://psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-co…
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - SPOTLIGHT CASE
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression
Citation Text:
Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - When the Meds Don’t Reach the Bed
Citation Text:
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. 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/perspective/conversation-withdavid-w-bates-md-msc
May 01, 2018 - In Conversation with…David W. Bates, MD, MSc
May 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…David W. Bates, MD, MSc. 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/838220/psn-pdf
September 27, 2019 - Primary Care and Patient Safety: Opportunities at the
Interface
September 28, 2022
O’Malley P, McNellis B, Chew E, et al. Primary Care and Patient Safety: Opportunities at the Interface.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
Editor’s Not…
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psnet.ahrq.gov/innovation/battle-buddies-rapid-deployment-psychological-resilience-intervention-health-care
September 09, 2020 - EMERGING INNOVATIONS
Battle Buddies: rapid deployment of a psychological resilience intervention for health care workers during the COVID-19 pandemic
Citation Text:
Albott CS, Wozniak JR, McGlinch BP, et al. Battle Buddies: rapid deployment of a psychological resilience intervention for health car…
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psnet.ahrq.gov/node/33575/psn-pdf
March 15, 2025 - Patient Engagement and Safety
March 15, 2025
Patient Engagement and Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-engagement-and-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the pati…
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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - Measuring engagement in a collaborative learning health system: the case of ImproveCareNow.
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Measuring engagement in a collaborative learning health system: the case of ImproveCareNow.
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psnet.ahrq.gov/perspective/response-failure-report-march-2007
June 01, 2007 - In response to "Failure to Report" (March 2007)
June 1, 2007
View more articles from the same authors.
Citation Text:
Paparella S, Vaida AJ, Spath P. In response to "Failure to Report" (March 2007). PSNet [internet]. Rockville (MD): Agency for Healthcare Research …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.104_slideshow.ppt
September 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case September 2005
Double Trouble
Source and Credits
This presentation is based on the Sept. 2005
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Jerry H. Gurwitz, MD, University of…
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psnet.ahrq.gov/primer/teamwork-training
September 15, 2024 - Teamwork Training
Citation Text:
Teamwork Training. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Dow…
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psnet.ahrq.gov/node/33569/psn-pdf
June 15, 2024 - Readmissions and Adverse Events After Discharge
June 15, 2024
Readmissions and Adverse Events After Discharge. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
t…
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psnet.ahrq.gov/node/33578/psn-pdf
September 15, 2024 - Human Factors Engineering
September 15, 2024
Human Factors Engineering. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/human-factors-engineering
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safe…
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psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior
September 15, 2024 - Disruptive and Unprofessional Behavior
Citation Text:
Disruptive and Unprofessional Behavior. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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