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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…
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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…
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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…
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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 …
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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…
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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…
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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…
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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…
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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
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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.
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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
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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
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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
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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
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - Joint Commission on Accreditation of Healthcare Organizations Web site.
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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
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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.
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psnet.ahrq.gov/node/49618/psn-pdf
February 01, 2011 - I believe
the professional organizations, from medical practices to hospital to medical societies and
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psnet.ahrq.gov/node/49807/psn-pdf
October 01, 2017 - Federal policies require that health care organizations that receive federal funding
take reasonable
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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