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psnet.ahrq.gov/node/866839/psn-pdf
September 25, 2024 - Errors in Managing an Open Wound of the Elbow Leading
to Multiple Complications and Operations
September 25, 2024
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications
and Operations. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/errors-managing-open-wound-elb…
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psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - Spotlight
Spotlight
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
1
Source and Credits
This presentation is based on the September 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: David…
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psnet.ahrq.gov/node/44268/psn-pdf
November 23, 2016 - A patient-initiated voluntary online survey of adverse
medical events: the perspective of 696 injured patients
and families.
November 23, 2016
Southwick FS, Cranley NM, Hallisy JA. A patient-initiated voluntary online survey of adverse medical
events: the perspective of 696 injured patients and families. BMJ Qual …
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psnet.ahrq.gov/node/46296/psn-pdf
September 24, 2017 - Perception of safety of surgical practice among operating
room personnel from survey data is associated with all-
cause 30-day postoperative death rate in South Carolina.
September 24, 2017
Molina G, Berry WR, Lipsitz S, et al. Perception of Safety of Surgical Practice Among Operating Room
Personnel From Survey Da…
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psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
March 01, 2011 - In Conversation with…Vineet Arora, MD, MA
March 1, 2011
Also Read an Essay
Citation Text:
In Conversation with…Vineet Arora, MD, MA . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. …
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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx
Spotlight
The Risks of a Malpositioned Gastrostomy Tube and
Poor Communication
Source and Credits
• This presentation is based on the November 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahr…
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psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - Patient Safety During Hospital Discharge
Katherine Liang and Eric Alper, MD | April 1, 2018
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. Rockville…
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psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
May 01, 2013 - In Conversation With… Ashish K. Jha, MD, MPH
May 1, 2013
Also Read an Essay
Citation Text:
In Conversation With… Ashish K. Jha, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013…
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - Risk Management and Patient Safety
Barry M. Manuel, MD; Jack L. McCarthy; William Berry, MD, MPH; Kathy Dwyer | December 1, 2010
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Manuel BM, McCarthy JL, Berry WR, et al. Risk Mana…
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psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
December 01, 2009 - In Conversation with…Gerald B. Hickson, MD
December 1, 2009
Also Read an Essay
Citation Text:
In Conversation with…Gerald B. Hickson, MD . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM
April 1, 2018
Also Read an Essay
Citation Text:
In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
December 01, 2009 - How to Identify and Manage Problem Behaviors
Alan H. Rosenstein, MD, MBA; Michelle O'Daniel, MSG, MHA | December 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Rosenstein AH, O'Daniel M. How to Identify and Manage Prob…
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psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety?
Kathlyn E. Fletcher, MD, MA; Darcy A. Reed, MD, MPH | April 1, 2013
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Fletcher KE, Reed DA. Are Residency Duty Hour Rules Imp…
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psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Vogus T, Lee M, Mos…
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psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - Course graduates are mentoring students as they participate in regional and national QI organizations
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psnet.ahrq.gov/node/33745/psn-pdf
February 01, 2013 - Patient Engagement and Patient Safety
February 1, 2013
Weingart SN. Patient Engagement and Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
Perspective
Patient engagement has arrived at the station. A Google search of this phrase identified 335,000 hi…
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psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training
October 01, 2004 - What Does Simulation Add to Teamwork Training?
David M. Gaba, MD | March 1, 2006
View more articles from the same authors.
Citation Text:
Gaba DM. What Does Simulation Add to Teamwork Training?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - patient
10-20 staff may see patient daily, facilitating disorientation
Source of cognitive stimulation
Participate
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.290_slideshow.ppt
February 01, 2013 - lawsuit
*
*
Patient’s Responsibility
From a legal perspective, patients also have a duty to participate
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psnet.ahrq.gov/node/33827/psn-pdf
February 01, 2017 - New Insights About Team Training From a Decade of
TeamSTEPPS
February 1, 2017
Baker DP, King HB, Battles J. New Insights About Team Training From a Decade of TeamSTEPPS. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
Perspective
Ten years ago, the Ag…