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psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
December 22, 2018 - WebM&M Cases
If You Say So: Taking a Syringe at Face Value in the Operating
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psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
March 01, 2007 - Following an RCA of this event, the operating room (OR) manager was instructed to evaluate all OR supplies
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psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
March 01, 2017 - Or are there fundamental changes that occur once you're now operating in a digital environment? … September 18, 2024
Factors associated with the use of cognitive aids in operating room
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psnet.ahrq.gov/node/60652/psn-pdf
June 29, 2020 - In Conversation With... Anna Legreid Dopp, Pharm. D
June 29, 2020
In Conversation With.. Anna Legreid Dopp, Pharm. D. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
Editor’s note: Anna Legreid Dopp, Pharm. D is the Senior Director of Clinical Guidelines and Quality…
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - must ensure the safe transition of the patient, as well as maintaining the safety of bystanders by operating
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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Despite Clues, Failed to Rescue
August 1, 2017
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
Case Objectives
Define failure to rescue.
Identify the main contributors to failure-to-rescue events.
Appreciate the ongoing areas of scien…
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psnet.ahrq.gov/node/861738/psn-pdf
January 31, 2024 - A Laceration that Needed a Proper Exam, Not an X-Ray
January 31, 2024
Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
Disclosure of Relevant Financial Relationships: As a provider accredited by t…
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psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
January 01, 2024 - Spotlight
Spotlight
Laceration that Needed a Proper Exam, Not an X-Ray
Source and Credits
• This presentation is based on the January 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: Jazmin A. Wander, MD and David K. Barnes, MD,
F…
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - SPOTLIGHT CASE
Patient Safety Events Involving Opioid Dose Stacking
Citation Text:
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
Copy Cita…
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psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
October 24, 2021 - Community pharmacies are sometimes equated to retail pharmacies, operating out of both large and small
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psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
September 01, 2007 - The nurses describe the fact that in the operating room they never witness from my generation of surgeons … But when I'm in the operating room or seeing a patient in the clinic or heading down to the ED, at that
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psnet.ahrq.gov/node/853902/psn-pdf
September 27, 2023 - A Missed Bowel Perforation - the Importance of
Diagnostic Reasoning
September 27, 2023
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
Disclosure of …
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - SPOTLIGHT CASE
A Missed Bowel Perforation - the Importance of Diagnostic Reasoning
Citation Text:
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
January 01, 2008 - In Conversation with…Jennifer Daley, MD
January 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Jennifer Daley, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Co…
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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
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Hauck LD, Jacob J. Implementing a Patient Safety …
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psnet.ahrq.gov/issue/medical-disrespect
September 27, 2023 - Newspaper/Magazine Article
Medical disrespect.
Citation Text:
Medical disrespect. Yurkiewicz I. Aeon Magazine. January 29, 2014.
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psnet.ahrq.gov/issue/learning-disasters-management-approach-third-ed
June 18, 2013 - Book/Report
Learning from Disasters: A Management Approach. Third ed.
Citation Text:
Learning from Disasters: A Management Approach. Third ed. Toft B, Reynolds S. Leicester, UK: Perpetuity Press Limited; 2005. ISBN: 9781349279029.
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psnet.ahrq.gov/issue/hospitals-scramble-front-lines-drug-shortages
November 29, 2016 - Newspaper/Magazine Article
Hospitals scramble on the front lines of drug shortages.
Citation Text:
Hospitals scramble on the front lines of drug shortages. Sun LH. Washington Post. April 10, 2012.
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psnet.ahrq.gov/issue/medication-errors-involving-overrides-healthcare-technology
January 11, 2017 - Newspaper/Magazine Article
Medication errors involving overrides of healthcare technology.
Citation Text:
Medication errors involving overrides of healthcare technology. Grissinger M. PA-PSRS Patient Saf Advis. December 2015;12:141-148.
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psnet.ahrq.gov/issue/ahrq-risk-informed-intervention-development-and-implementation-safe-practices-ambulatory-care
December 24, 2008 - Grant Recipient
AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care.
Citation Text:
AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care. Rockville, MD: Agency for Healthcare Research and…