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psnet.ahrq.gov/node/47555/psn-pdf
November 14, 2018 - How one hospital improved patient safety in 10 minutes a
day.
November 14, 2018
van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.
https://psnet.ahrq.gov/issue/how-one-hospital-improved-patient-safety-10-minutes-day
Aviation continues to provide inspiration for patient safety innovation. This commentar…
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psnet.ahrq.gov/node/34839/psn-pdf
April 06, 2011 - Communication failures in the operating room: an
observational classification of recurrent types and
effects.
April 6, 2011
Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational
classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330-4.
http…
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psnet.ahrq.gov/node/45031/psn-pdf
February 18, 2017 - Information transfer in multidisciplinary operating room
teams: a simulation-based observational study.
February 18, 2017
Cumin D, Skilton C, Weller J. Information transfer in multidisciplinary operating room teams: a simulation-
based observational study. BMJ Qual Saf. 2017;26(3):209-216. doi:10.1136/bmjqs-2015-00…
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psnet.ahrq.gov/node/42638/psn-pdf
October 09, 2013 - Strengths and weaknesses of working with the Global
Trigger Tool method for retrospective record review:
focus group interviews with team members.
October 9, 2013
Schildmeijer K, Nilsson L, Perk J, et al. Strengths and weaknesses of working with the Global Trigger Tool
method for retrospective record review: focus…
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psnet.ahrq.gov/perspective/medias-role-patient-safety
April 27, 2022 - The AP did stories on its own, and any story from a member could be condensed by the AP and sent out
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psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
August 01, 2019 - median, we took the cost of the scribes and running the program, figured out what it costs per faculty member
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psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
March 01, 2008 - resident multiple, condensed opportunities for deliberate practice and allows the assigned faculty member
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psnet.ahrq.gov/perspective/conversation-michael-l-millenson
April 27, 2022 - The AP did stories on its own, and any story from a member could be condensed by the AP and sent out
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psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
February 26, 2025 - In Conversation with...Brent C. James, MD, MStat
February 1, 2011
Citation Text:
In Conversation with..Brent C. James, MD, MStat. PSNet [internet]. 2011.In Conversation with...Brent C. James, MD, MStat. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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psnet.ahrq.gov/node/853081/psn-pdf
August 30, 2023 - In Conversation with... Kathleen Sanford and Sue
Schuelke about Virtual Nursing
August 30, 2023
Sanford K, Schuelke S, Lee M, et al. In Conversation with.. Kathleen Sanford and Sue Schuelke about
Virtual Nursing. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schue…
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psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - SPOTLIGHT CASE
"Do You Want Everything Done?": Clarifying Code Status
Citation Text:
Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
…
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psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
April 01, 2005 - In Conversation with…Christopher P. Landrigan, MD
April 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
April 01, 2005 - Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet)
Robert M. Wachter, MD | April 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wachter R. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Ne…
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psnet.ahrq.gov/node/838221/psn-pdf
September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH
September 28, 2022
In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
Editor’s Note: Freya Spielberg, MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social
enterp…
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psnet.ahrq.gov/node/838222/psn-pdf
September 28, 2022 - In Conversation With... Jack Westfall, MD, MPH
September 28, 2022
In Conversation With.. Jack Westfall, MD, MPH. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
Editor’s note: Jack Westfall, MD, MPH, is a retired professor from the University of Colorado School of
Medic…
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psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
January 01, 2024 - Spotlight
Spotlight
Missed Connection: A Case of Inadequate ECG
Oversight in Cardiac Surgery
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Christian Bohringer, MBBS, …
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psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight
in Cardiac Surgery
April 24, 2024
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac
Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery…
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psnet.ahrq.gov/node/33861/psn-pdf
July 01, 2018 - In Conversation With… Gordon Schiff, MD
July 1, 2018
In Conversation With… Gordon Schiff, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
Editor's note: Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research
and Practice, Associate Pr…
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - Care Managers Use Software-Aided Medication Review
Protocol for Frail, Community-Dwelling Seniors, Leading
to More Appropriate Medication Use
March 31, 2021
https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-
community-dwelling
Summary
Care management staff (such …
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - A Case of Mistaken Capacity: Why A Thorough
Psychosocial History Can Improve Care.
March 31, 2022
Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve
Care. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-c…