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psnet.ahrq.gov/web-mm/complaints-safety-surveillance
May 05, 2021 - Organizations like Vanderbilt University have demonstrated the benefits of systematically identifying
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - errors in their landmark report, Improving Diagnosis in Health Care. ( 11 ) The report encourages organizations
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psnet.ahrq.gov/web-mm/code-blue-where
March 30, 2020 - Joint Commission of Accreditation of Healthcare Organizations: accreditation manual for hospitals.
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Spotlight
Spotlight
Dangers of Missing an Epidural Abscess:
Multiple Visits and Delayed Diagnosis with
a Severely Negative Outcome
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 Comm…
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psnet.ahrq.gov/node/861881/psn-pdf
January 31, 2024 - I work with professional organizations, with health systems, and with
individuals to develop and operationalize
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Adoption Considerations Use by Others (Use By Other Organizations)
In addition to use at the Alfred
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psnet.ahrq.gov/node/33674/psn-pdf
February 01, 2009 - fraction of that—one fiftieth or one hundredth of that when you
look at the budget of AHRQ and other organizations
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psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
May 11, 2019 - May 11, 2019
Where trust flourishes: perceptions of clinicians who trust their organizations
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - Neither report offers specific dosing guidance; both organizations recommend individualizing therapy … The data in PDMPs are state-specific and various settings/organizations in addition to hospitals, such
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - Simultaneously, policymakers and individual EMS organizations are considering the expansion of EMS’ role … Perspective
Patient Safety Events and the Role of Patient Safety Organizations
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psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
March 27, 2024 - RW : That's what you're doing at the level of an individual health care organization.
-
psnet.ahrq.gov/node/33858/psn-pdf
May 01, 2018 - RW: That's what you're doing at the level of an individual health care organization.
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psnet.ahrq.gov/perspective/what-makes-good-checklist
October 01, 2010 - I begin with how Josie King's death really impacted my organization and me personally.
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - I begin with how Josie King's death really impacted my organization and me personally.
-
psnet.ahrq.gov/node/49820/psn-pdf
February 01, 2018 - Returning Home Safely
February 1, 2018
Toles M. Returning Home Safely. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/returning-home-safely
The Case
A 72-year-old man was admitted to the hospital after a fall at home resulting in a right humerus fracture and
shoulder dislocation, as well as other injuries …
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - Staggered Sensitivity Results
Citation Text:
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
-
psnet.ahrq.gov/web-mm/failure-reevaluate
February 01, 2014 - Failure to Reevaluate
Citation Text:
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
-
psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
January 01, 2022 - Spotlight
Spotlight
Strongyloides: A Hidden Traveler
and Potentially Lethal Missed
Diagnosis
Source and Credits
• This presentation is based on the November 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Narath Carlile MD MPH,…
-
psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - A Seasonal Care Transition Failure
July 1, 2011
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
The Case
A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine
resident—for routine follow-up…
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psnet.ahrq.gov/node/49576/psn-pdf
January 01, 2009 - To Transfer or Not to Transfer
January 1, 2009
Pines JM. To Transfer or Not to Transfer. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/transfer-or-not-transfer
Case Objectives
Explore the benefits of the continuity of hospital care.
Understand the rules and regulations behind triage and hospital choice de…