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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - SPOTLIGHT CASE
Discharge Fumbles
Citation Text:
Forster AJ. Discharge Fumbles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
September 22, 2010 - Inappropriate Antibiotic Use
Citation Text:
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - Root Cause Analysis Gone Wrong
Citation Text:
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Jaenic Lee, MD Josh Fernel…
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - Personal Health Literacy
August 30, 2023
Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/personal-health-literacy
Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in
August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…
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psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
January 01, 2024 - Spotlight
Spotlight
A Fatal Twist in Pseudohyperkalemia
1
Source and Credits
This presentation is based on the August 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Le…
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance
Measurement Tracking, and Performance Feedback
February 28, 2024
https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-
and-performance
Summary
To improve patient care and outcomes in the intensive care unit (ICU…
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
Citation Text:
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - In Conversation with...James P. Bagian, MD
September 1, 2006
Also Read an Essay
Also Read an Essay
Citation Text:
In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.In Conversation with...James P. Bagian, MD. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
August 01, 2018 - How Does Health Care Simulation Affect Patient Care?
Joseph O. Lopreiato, MD, MPH | August 1, 2018
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Lopreiato JO. How Does Health Care Simulation Affect Patient Care?. PSNet [inter…
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety
Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD
| August 30, 2023
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Van CM, Mossb…
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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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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…