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psnet.ahrq.gov/issue/junior-medics-bullied-lie-about-hours-doctors-ordered-work-without-proper-training
April 27, 2016 - January 17, 2018
Becoming a high-reliability organization through shared learning of
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - SPOTLIGHT CASE
Don't Dismiss the Dangerous: Obstetric Hemorrhage
Citation Text:
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
…
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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/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - Spotlight
Spotlight
Fatal PCA Opioid-Induced
Respiratory Depression
Source and Credits
• This presentation is based on the May 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Sarina Fazio, PhD, RN and Rachelle
Firestone, PharmD, BCCCP
o Editors in Chie…
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psnet.ahrq.gov/web-mm/shake-well
September 01, 2006 - Because the healthcare organization had switched carbamazepine formulations at all its member hospitals
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
November 01, 2006 - data sources can be valuable tools for case identification and the monitoring of rates at a single organization
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psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - The
World Health Organization Vaccine Safety Basics e-learning course is a fine example with international
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - And in 2017, the World Health Organization launched its Medication Without Harm program as part of
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psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
November 01, 2017 - patient and provider uptake of patient-facing technologies, such as personal health records.( 14 ) Organizations
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psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma
February 26, 2025 - Interview
In Conversation with Timothy Vogus about High Reliability Organization
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - 15)
Culture of Safety
(39)
Just Culture
(1)
Learning Organization
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psnet.ahrq.gov/perspective/safety-dentistry
August 01, 2016 - A dental team is much smaller, and usually the person in charge of the organization of care and the person
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psnet.ahrq.gov/node/49509/psn-pdf
April 01, 2006 - Insert Omission
April 1, 2006
Darney P. Insert Omission. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/insert-omission
The Case
A multiparous woman presented to the gynecology clinic requesting intrauterine contraceptive (IUC)
placement (Figure). She was appropriately counseled on the risks and benefits o…
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psnet.ahrq.gov/node/33781/psn-pdf
March 01, 2015 - In Conversation With… Brian Jarman, PhD
March 1, 2015
In Conversation With… Brian Jarman, PhD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
Editor's note: Sir Brian Jarman is an emeritus professor at Imperial College School of Medicine and a
past president of the Britis…
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psnet.ahrq.gov/web-mm/coming-short
May 20, 2020 - Coming Up Short
Citation Text:
Hochberg Z'ev. Coming Up Short. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - PowerPoint Presentation
Spotlight
The Hazards of Distraction: Ticking All the EHR Boxes
*
Source and Credits
This presentation is based on the February 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
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psnet.ahrq.gov/node/845472/psn-pdf
March 15, 2023 - Within an accountable care organization (ACO), the incentives might be different because we have
financial … At organizations that are larger, everyone may be
working at full capacity or over capacity.
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psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
February 01, 2014 - impact, but a lot of the work you do has to be mediated through or certainly influenced by other federal organizations … that has its own politics, you always need to consider the obstacles to accomplishing the goals of the organization
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psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - But the hospital is also a very complex functional organization. … RW: How would you try to apply this thinking in a health care organization?
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psnet.ahrq.gov/issue/ismp-survey-2022-2023-targeted-medication-safety-best-practices-hospitals
January 26, 2023 - April 1, 2020
Errors associated with oxytocin use: a multi-organization analysis by ISMP