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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
January 01, 2019 - Spotlight
Spotlight
Mistaken Attribution, Diagnostic Misstep
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Source and Credits
This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD
…
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psnet.ahrq.gov/node/33704/psn-pdf
December 01, 2010 - In Conversation with...Geri Amori, PhD
December 1, 2010
In Conversation with..Geri Amori, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
Editor's note: Geri Amori, PhD, is Vice President for the Education Center at The Risk Management and
Patient Safety Institute, a…
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psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Transfer Troubles
June 1, 2012
Hains IM. Transfer Troubles. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfer-troubles
Case Objectives
Recognize that transfer of patients between hospitals is common.
Understand the frequency of errors and adverse events in the transfer of patients between hospitals.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - PowerPoint Presentation
Spotlight
A Lot of Pain (Medications)
1
This presentation is based on the September 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…
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psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx
Spotlight
Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full …
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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx
Spotlight
Challenging Case of Multiple Suicide Attempts in a
Complex Patient with Psychiatric Comorbidities
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Getting the Diagnosis Both Right and Wrong
Citation Text:
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3…
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psnet.ahrq.gov/web-mm/emergency-error
January 18, 2013 - SPOTLIGHT CASE
Emergency Error
Citation Text:
Symons NRA. Emergency Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - SPOTLIGHT CASE
The Hazards of Distraction: Ticking All the EHR Boxes
Citation Text:
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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…
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psnet.ahrq.gov/primer/long-term-care-and-patient-safety
February 24, 2022 - Long-term Care and Patient Safety
Citation Text:
Bakerjian D. Long-term Care and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
January 01, 2024 - The Different Count Contributions to Retention
Differential Count Contributions in Retained Surgical Sponge Cases: Examination of Administrative Penalty
Cases from the California Department of Public Health (CDPH), Health and Safety Code Section 1280.1
Enforcement Reports from 2007-2014
A NoThing Left Behin…
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psnet.ahrq.gov/node/843415/psn-pdf
February 01, 2023 - Explaining the negative effects of patient participation in
patient safety: an exploratory qualitative study in an
academic tertiary healthcare centre in the Netherlands.
February 1, 2023
Van der Voorden M, Ahaus K, Franx A. Explaining the negative effects of patient participation in patient
safety: an exploratory…
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - Abnormal Volunteer Results
Citation Text:
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
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psnet.ahrq.gov/issue/hospitalized-patients-attitudes-about-and-participation-error-prevention
December 22, 2008 - Study
Hospitalized patients' attitudes about and participation in error prevention.
Citation Text:
Waterman AD, Gallagher TH, Garbutt J, et al. Brief report: Hospitalized patients' attitudes about and participation in error prevention. J Gen Intern Med. 2006;21(4):367-70.
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psnet.ahrq.gov/issue/patient-participation-current-knowledge-and-applicability-patient-safety
February 01, 2011 - Commentary
Classic
Patient participation: current knowledge and applicability to patient safety.
Citation Text:
Longtin Y, Sax H, Leape L, et al. Patient participation: current knowledge and applicability to patient safety. Mayo Clin Proc. 2010;85(1):53-62. doi:…
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psnet.ahrq.gov/node/837896/psn-pdf
January 01, 2023 - Helping healthcare teams to debrief effectively:
associations of debriefers' actions and participants'
reflections during team debriefings.
August 24, 2022
Kolbe M, Grande B, Lehmann-Willenbrock N, et al. Helping healthcare teams to debrief effectively:
associations of debriefers’ actions and participants’ reflect…
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psnet.ahrq.gov/node/49538/psn-pdf
June 01, 2007 - Abnormal Volunteer Results
June 1, 2007
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results
The Case
A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent
magnetic resonance imaging (MRI) of her abdo…
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psnet.ahrq.gov/node/43907/psn-pdf
April 27, 2015 - Association of hospital participation in a surgical
outcomes monitoring program with inpatient
complications and mortality.
April 27, 2015
Etzioni DA, Wasif N, Dueck AC, et al. Association of hospital participation in a surgical outcomes
monitoring program with inpatient complications and mortality. JAMA. 2015;313…
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psnet.ahrq.gov/node/41626/psn-pdf
August 29, 2012 - Impact of resident participation in surgical operations on
postoperative outcomes: National Surgical Quality
Improvement Program.
August 29, 2012
Kiran RP, Ahmed Ali U, Coffey JC, et al. Impact of Resident Participation in Surgical Operations on
Postoperative Outcomes. Ann Surg. 2012;256(3):469-475. doi:10.1097/sl…
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psnet.ahrq.gov/node/34683/psn-pdf
February 10, 2011 - Pharmacist participation on physician rounds and
adverse drug events in the intensive care unit.
February 10, 2011
Leape L, Cullen DJ, Clapp M, et al. Pharmacist participation on physician rounds and adverse drug events
in the intensive care unit. JAMA. 1999;282(3):267-70.
https://psnet.ahrq.gov/issue/pharmacist-p…