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psnet.ahrq.gov/node/865373/psn-pdf
March 27, 2024 - Sarah Mossburg: In terms of strategies or practices for organizations that are integrating AI, would
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psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - Feasibility and Added Value of Executive WalkRounds in Long Term Care Organizations in the Netherlands
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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
September 27, 2023 - part of National Patient Safety Goal (NPSG) 15.01.01 for medical hospitals and behavioral health care organizations
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psnet.ahrq.gov/node/49749/psn-pdf
December 01, 2015 - The organization is responsible for training and assessing clinician competencies for technology
and … Organizations must have ongoing competency assessment and technology training to
support optimal performance … Other tools that organizations can use to prevent these errors include teamwork training and efforts … With the establishment of performance measurement for inpatient glycemic control (3,12), organizations … inadequate training of clinicians on technology are safety threats that must be
actively dealt with by organizations
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psnet.ahrq.gov/training-catalog/patient-safety-leadership-training-certification-course
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Organization … :
Organization
Duke University Health System Patient Safety Center
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psnet.ahrq.gov/training-catalog/advancing-care-conference
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Organization … :
Organization
American Hospital Association (AHA)
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psnet.ahrq.gov/training-catalog/19th-northwest-patient-safety-conference
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Organization … :
Organization
Washington Patient Safety Coalition (WPSC)
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psnet.ahrq.gov/training-catalog/anesthesia-quality-and-patient-safety-meeting
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Organization … :
Organization
American Society of Anesthesiologists
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Conclusion There are four straightforward prevention strategies for healthcare organizations to consider
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psnet.ahrq.gov/issue/resilience-engineering-concepts-and-precepts
January 12, 2011 - This book explores how organizations and individuals must anticipate risk and continuously adapt to the … October 13, 2010
Towards an organization with a memory: exploring the organizational … See More About The Topic
Risk Managers
Organizational Behaviorists
Engineers
Learning Organization
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psnet.ahrq.gov/web-mm/back-again
November 18, 2016 - SPOTLIGHT CASE
Back Again
Citation Text:
Lurie JD. Back Again. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis.
Citation Text:
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - SPOTLIGHT CASE
Palliative Care: Comfort vs. Harm
Citation Text:
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/dissecting-presentation
May 05, 2021 - SPOTLIGHT CASE
Dissecting the Presentation
Citation Text:
Suat-Ooi SB. Dissecting the Presentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - SPOTLIGHT CASE
Delayed Diagnosis of Mesenteric Ischemia
Citation Text:
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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…
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - SPOTLIGHT CASE
All in the History
Citation Text:
Fee C. All in the History. 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/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
January 13, 2010 - SPOTLIGHT CASE
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
Citation Text:
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - Delayed Diagnosis of Mesenteric Ischemia
August 31, 2022
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for…
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psnet.ahrq.gov/node/49721/psn-pdf
December 01, 2014 - Ebola: Are We Ready?
December 1, 2014
Barsuk JH, Barnard C. Ebola: Are We Ready? PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/ebola-are-we-ready
The Case
A 28-year-old man, well-appearing but pale, walked into the emergency department (ED) on a Wednesday
afternoon at 3 PM complaining of nausea, vomiting,…
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psnet.ahrq.gov/node/850450/psn-pdf
June 14, 2023 - The One That Got Away—Elopement of a Suicidal Patient
in the Emergency Department.
June 14, 2023
Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the
Emergency Department. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-…