- 
                                        
psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - Care Managers Use Software-Aided Medication Review
Protocol for Frail, Community-Dwelling Seniors, Leading
to More Appropriate Medication Use
March 31, 2021
https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-
community-dwelling
Summary
Care management staff (such … 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
July 10, 2024 - experience, and prevention of patient safety events and adverse events such as medication issues, falls, pressure … ulcers, and infections.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
July 10, 2024 - experience, and prevention of patient safety events and adverse events such as medication issues, falls, pressure … ulcers, and infections.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/need-eat
February 10, 2021 - treated as an ancillary concern that is not prioritized in acute care until overt symptoms, such a pressure … ulcers, significant weight loss or failure to thrive occur.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/50755/psn-pdf
December 18, 2019 - treated as
an ancillary concern that is not prioritized in acute care until overt symptoms, such a pressure … ulcers,
significant weight loss or failure to thrive occur.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
September 13, 2023 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use 
 
 
 
 
 
 
 
 
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 March 31… 
                                     
                                                                    - 
                                        
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… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
January 01, 2018 - Maybe she has a pressure ulcer that's red, inflamed. But trainees don't prioritize those things.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - Maybe she has a pressure ulcer that's red, inflamed. But trainees don't prioritize those things.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - for the more common types of events, such as health care–associated infections, medication errors, pressure … ulcers, falls, and a few others.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - for the more common types of events, such as health care–associated infections, medication errors, pressure … ulcers, falls, and a few others.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
March 27, 2024 - likelihood that a patient will  decompensate , have an adverse reaction to a medication, or develop a pressure … ulcer and then alerting clinicians if the risk is high enough.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
March 27, 2024 - likelihood that a patient will  decompensate , have an adverse reaction to a medication, or develop a pressure … ulcer and then alerting clinicians if the risk is high enough.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - SPOTLIGHT CASE
         
 The Risks of a Malpositioned Gastrostomy Tube and Poor Communication 
 
 
 
 
 Citation Text: 
 Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/857059/psn-pdf
November 29, 2023 - The Risks of a Malpositioned Gastrostomy Tube and Poor
Communication
November 29, 2023
Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet].
2023.
https://psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
Disclosure of Relevant Financial …