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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.191_slideshow.ppt
January 01, 2009 - Spotlight Case July 2008
Spotlight Case January 2009
To Transfer or Not to Transfer
Source and Credits
This presentation is based on the January 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jesse M. Pines, MD, MBA, MSCE
University o…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
May 01, 2011 - Spotlight Case July 2008
Spotlight Case
Duty to Disclose Someone Else’s Error
*
*
Source and Credits
This presentation is based on the May 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Thomas H. Gallagher, MD University of Washington
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
September 01, 2011 - Spotlight Case July 2008
Spotlight Case
The Safety and Quality of Long Term Care
*
*
Source and Credits
This presentation is based on the September 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Amy A. Vogelsmeier, PhD, RN, GCNS-BC, Uni…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Bad Writing, Wrong Medication
*
*
Source and Credits
This presentation is based on the April 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Beth Devine, PharmD, MBA, PhD
University of Washingto…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.365_slideshow.ppt
January 01, 2016 - PowerPoint Presentation
Spotlight
A Room Without Orders
1
This presentation is based on the January 2016
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Amy Vogelsmeier, PhD, RN, Sinclair School of Nursing; and Laurel Despins, PhD, RN, Sinclair Sc…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.95_slideshow.ppt
May 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case May 2005
Diagnosing Diagnostic Mistakes
Source and Credits
This presentation is based on the May 2005 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Robert McNutt, MD; Richard A…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.221_slideshow.ppt
July 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Weighing in on Surgical Safety
*
*
Source and Credits
This presentation is based on the July 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jay B. Brodsky, MD, Stanford University Medical Cente…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.293_slideshow.ppt
March 01, 2013 - Spotlight Case July 2008
Spotlight Case
A Weighty Mistake
*
*
Source and Credits
This presentation is based on the March 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Seth J. Bokser, MD, MPH, Associate Professor of Pediatrics & Medical…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
February 01, 2018 - PowerPoint Presentation
Spotlight
Signout Fallout
1
Source and Credits
This presentation is based on the February 2018
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…
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psnet.ahrq.gov/primer/root-cause-analysis
March 30, 2022 - Root Cause Analysis
Citation Text:
Root Cause Analysis. 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 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/primer/ambulatory-care-safety
December 15, 2024 - Ambulatory Care Safety
Citation Text:
Ambulatory Care Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
March 30, 2022 - Adverse Events, Near Misses, and Errors
Citation Text:
Adverse Events, Near Misses, and Errors. 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 XML EndNote 7 X…
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psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
November 27, 2023 - academia, whether it’s at the faculty or leadership level, we’ve seen multiple opportunities for research participation
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psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
November 27, 2023 - academia, whether it’s at the faculty or leadership level, we’ve seen multiple opportunities for research participation
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psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
April 01, 2006 - Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.
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psnet.ahrq.gov/web-mm/dropping-new-lows
December 18, 2024 - SPOTLIGHT CASE
Dropping to New Lows
Citation Text:
Juang PC, Kulasa K. Dropping to New Lows. 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/node/865884/psn-pdf
May 29, 2024 - Managing Complexity in Diagnosis: Life-threatening
Complications after Gastric Bypass Surgery.
May 29, 2024
Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass
Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-…
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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Despite Clues, Failed to Rescue
August 1, 2017
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
Case Objectives
Define failure to rescue.
Identify the main contributors to failure-to-rescue events.
Appreciate the ongoing areas of scien…
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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/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - SPOTLIGHT CASE
Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees
Citation Text:
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…