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psnet.ahrq.gov/web-mm/peripheral-iv-too-long
September 15, 2011 - SPOTLIGHT CASE
Peripheral IV in Too Long
Citation Text:
Fang C-T. Peripheral IV in Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/perspective/communication-during-transitions-care
July 10, 2024 - Annual Perspective
Communication During Transitions of Care
Ayse P. Gurses; Sarah Mossburg; Zoe Sousane
| March 27, 2024
View more articles from the same authors.
Citation Text:
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PS…
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
Citation Text:
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/curated-library/artificial-intelligence-system-level-considerations
March 27, 2024 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Artificial Intelligence: System-Level Considerations
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Created By: Lorri Zipper…
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psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - SPOTLIGHT CASE
Elopement
Citation Text:
Gerardi D. Elopement. 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/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - SPOTLIGHT CASE
Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump
Citation Text:
Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump . PSNet [internet]. Rockville (MD): Agency for Heal…
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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors
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March 3, 2021
Innovation…
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psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
May 01, 2012 - In Conversation With…David C. Classen, MD, MS
May 1, 2012
Also Read an Essay
Citation Text:
In Conversation With…David C. Classen, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety
Paul J. Sharek, MD, MPH | May 1, 2012
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Sharek PJ. The Emergence of the Trigger Tool as the …
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - SPOTLIGHT CASE
Delirium or Dementia?
Citation Text:
Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
December 01, 2012 - SPOTLIGHT CASE
"The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety
Citation Text:
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
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psnet.ahrq.gov/web-mm/forgotten-turn
August 01, 2018 - SPOTLIGHT CASE
The Forgotten Turn
Citation Text:
Barbour S. The Forgotten Turn. 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/60610/psn-pdf
June 24, 2020 - Endometriosis: A Common and Commonly Missed and
Delayed Diagnosis
June 24, 2020
Mackenzie M, Royce C. Endometriosis: A Common and Commonly Missed and Delayed Diagnosis. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis
The Case
A 15-year-old g…
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - SPOTLIGHT CASE
Right Regimen, Wrong Cancer: Patient Catches Medical Error
Citation Text:
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
April 03, 2024 - SPOTLIGHT CASE
Medication Reconciliation With a Twist (or Dare We Say, a Patch?)
Citation Text:
Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - SPOTLIGHT CASE
Multifactorial Medication Mishap
Citation Text:
Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/863649/psn-pdf
February 28, 2024 - In Conversation With...Stephen Hines, PhD and Monika
Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS
3.0
February 28, 2024
In Conversation With..Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about
TeamSTEPPS 3.0. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withstephen-…
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psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - Hidden Danger! Insidious Postpartum Bleeding After
Emergency Cesarean Delivery.
November 30, 2021
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean
Delivery. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emerg…
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psnet.ahrq.gov/node/50754/psn-pdf
December 18, 2019 - "Do You Want Everything Done?": Clarifying Code Status
December 18, 2019
Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
Disclosure of Relevant Financial Relationships: As a p…
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx
Spotlight
Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See…