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  1. psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
    January 01, 2020 - Spotlight Too Many Cooks in the Kitchen Source and Credits • This presentation is based on the August 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Richard P. Dutton, MD, MBA o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72693/psn-pdf
    January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…
  3. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
    January 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case January 2008 How Do Providers Recover from Errors? Source and Credits This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Colin P. West, MD, PhD, Mayo Clini…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33845/psn-pdf
    November 01, 2017 - In Conversation With… Wanda Pratt, PhD November 1, 2017 In Conversation With… Wanda Pratt, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd Editor's note: Wanda Pratt is a Professor in the Information School with an adjunct appointment in the Division of Biomedical and …
  5. psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
    April 28, 2021 - Procedural Mishap: Learning Curve? Citation Text: Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.182_slideshow.ppt
    September 01, 2008 - Spotlight Case July 2008 Spotlight Case Empiric Steroids: the Good, the Bad, and the Ugly Source and Credits This presentation is based on the September 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Edward D. Harris, Jr, MD, Stanford U…
  7. psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
    May 01, 2006 - Medication Reconciliation Pitfalls Citation Text: Weber RJ. Medication Reconciliation Pitfalls. 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 X…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73902/psn-pdf
    September 29, 2021 - Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome September 29, 2021 Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet]. 2021. https://psnet.ahrq.go…
  9. psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
    May 01, 2012 - And, we found voluntary reporting picked up no adverse events at that organization. … States hospitals.( 1 ) In response to these disturbing data, accreditation bodies, payers, nonprofit organizations
  10. psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
    May 01, 2012 - States hospitals.( 1 ) In response to these disturbing data, accreditation bodies, payers, nonprofit organizations … And, we found voluntary reporting picked up no adverse events at that organization.
  11. psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
    June 01, 2007 - To Err Is Human observed, external reporting systems can help create an environment that encourages organizations
  12. psnet.ahrq.gov/web-mm/case-mistaken-intubation
    July 01, 2016 - another; Epic, for example, has "Care Everywhere," which allows customers in different health care organizations
  13. psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
    December 07, 2009 - follow-up system.( 3 ) Accordingly, follow-up of outpatient test results has become a major priority for organizations
  14. psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
    January 01, 2009 - In response to some of the unintended negative consequences of PACS, many organizations have been developing
  15. psnet.ahrq.gov/web-mm/moving-pains
    August 17, 2017 - Joint Commission on Accreditation of Healthcare Organizations Web site.
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50611/psn-pdf
    October 30, 2019 - Surescripts has built a network to link prescribers, pharmacy benefit managers, pharmacies, and many other organizations
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49486/psn-pdf
    August 21, 2005 - Such a vision may be realized in many health care organizations in the next few years. Richard H.
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49618/psn-pdf
    February 01, 2011 - I believe the professional organizations, from medical practices to hospital to medical societies and
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49807/psn-pdf
    October 01, 2017 - Federal policies require that health care organizations that receive federal funding take reasonable
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836885/psn-pdf
    May 16, 2022 - psnet.ahrq.gov//#3 knowledge competencies.4 Logistically, it may be impossible for many health care organizations

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