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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication
Breakdown.
August 30, 2023
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Spotlight
Spotlight
Prolonged DKA in Pregnancy: A Case of Communication
Breakdown
Source and Credits
• This presentation is based on the August 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarah Marshall, MD and Nina M. …
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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/node/45123/psn-pdf
May 07, 2018 - Hardwiring safety into the computer system: one
hospital's actions to provide technology support for U-
500 insulin.
May 7, 2018
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2016;21:1-4.
https://psnet.ahrq.gov/issue/hardwiring-safety-computer-system-one-hospitals-actions-provide-technology-
support-u-…
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psnet.ahrq.gov/node/861838/psn-pdf
January 31, 2024 - Adverse Drug Event (ADE) Surveillance and Pharmacist
Counseling
January 31, 2024
https://psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
Summary
Adverse events resulting from medications are a common occurrence that often go undetected, unreported,
and unaddressed.1 The imp…
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psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
July 10, 2024 - Health Plan Patient Safety Initiatives
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Helwig A, Sousane Z, Mossburg S. Health Plan Patient S…
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psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
July 10, 2024 - In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024
Also Read the Essay
View more articles from the same authors.
Citation Text:
Helwig A, Sousane Z, …
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psnet.ahrq.gov/node/33856/psn-pdf
April 01, 2018 - Patient Safety During Hospital Discharge
April 1, 2018
Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
Perspective
Patients are admitted to the hospital in the United States 35 million times per year.(1)…
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psnet.ahrq.gov/node/33629/psn-pdf
March 01, 2006 - What Does Simulation Add to Teamwork Training?
March 1, 2006
Gaba DM. What Does Simulation Add to Teamwork Training? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training
Editor's Note: In these point–counterpoint articles, Drs. Pratt and Sachs of Beth Israel Deacones…
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psnet.ahrq.gov/node/49685/psn-pdf
May 01, 2013 - Polypharmacy
May 1, 2013
Guglielmo JB. Polypharmacy. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/polypharmacy
The Case
A 65-year-old man with schizophrenia receives his routine outpatient psychiatric care through an agency.
His case manager visits him weekly regarding medication adherence, which include…
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psnet.ahrq.gov/node/44236/psn-pdf
October 13, 2015 - We thought we would be perfect: medication errors
before and after the initiation of computerized physician
order entry.
October 13, 2015
Schwartzberg D, Ivanovic S, Patel S, et al. We thought we would be perfect: medication errors before and
after the initiation of Computerized Physician Order Entry. J Surg Res. …
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psnet.ahrq.gov/node/47489/psn-pdf
November 21, 2018 - Impact of the Care Quality Commission on Provider
Performance: Room for Improvement?
November 21, 2018
Smithson R, Richardson E, Roberts J, et al. The King's Fund, Alliance Manchester Business School;
September 2018. ISBN: 9781909029880.
https://psnet.ahrq.gov/issue/impact-care-quality-commission-provider-performa…
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psnet.ahrq.gov/node/45765/psn-pdf
April 05, 2017 - Clinical reasoning in the context of active decision
support during medication prescribing.
April 5, 2017
Horsky J, Aarts J, Verheul L, et al. Clinical reasoning in the context of active decision support during
medication prescribing. Int J Med Inform. 2017;97:1-11. doi:10.1016/j.ijmedinf.2016.09.004.
https://psne…
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psnet.ahrq.gov/node/34694/psn-pdf
February 10, 2011 - Computerized surveillance of adverse drug events in
hospital patients.
February 10, 2011
Classen DC, Pestotnik SL, Evans RS, et al. Computerized surveillance of adverse drug events in hospital
patients. JAMA. 1991;266(20):2847-51.
https://psnet.ahrq.gov/issue/computerized-surveillance-adverse-drug-events-hospital-…
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psnet.ahrq.gov/node/38690/psn-pdf
April 07, 2010 - Are verbal orders a threat to patient safety?
April 7, 2010
Wakefield DS, Wakefield BJ. Are verbal orders a threat to patient safety? Qual Saf Health Care.
2009;18(3):165-168. doi:10.1136/qshc.2009.034041.
https://psnet.ahrq.gov/issue/are-verbal-orders-threat-patient-safety
Verbal orders (VOs) are often complex co…
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psnet.ahrq.gov/node/46359/psn-pdf
September 21, 2017 - Parent–provider miscommunications in hospitalized
children.
September 21, 2017
Khan A, Furtak SL, Melvin P, et al. Parent-Provider Miscommunications in Hospitalized Children. Hosp
Pediatr. 2017;7(9):505-515. doi:10.1542/hpeds.2016-0190.
https://psnet.ahrq.gov/issue/parent-provider-miscommunications-hospitalized-ch…
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psnet.ahrq.gov/node/864851/psn-pdf
March 20, 2024 - The Joint Commission's ongoing professional practice
evaluation process: costly, ineffective, and potentially
harmful to safety culture.
March 20, 2024
Donnelly LF, Podberesky DJ, Towbin AJ, et al. The Joint Commission's ongoing professional practice
evaluation process: costly, ineffective, and potentially harmful…
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psnet.ahrq.gov/node/858174/psn-pdf
December 13, 2023 - Anaesthesia clinicians' perception of safety, workload,
anxiety, and stress in a remote hybrid suite compared
with the operating room.
December 13, 2023
Schroeck H, Whitty MA, Martinez-Camblor P, et al. Anaesthesia clinicians' perception of safety, workload,
anxiety, and stress in a remote hybrid suite compared wi…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
December 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case December 2004
Discharge Fumbles
Source and Credits
This presentation is based on the Dec. 2004
AHRQ WebM&M Spotlight Case in Hospital Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Alan Forster, M…
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psnet.ahrq.gov/issue/schwartz-center-rounds-evaluation-interdisciplinary-approach-enhancing-patient-centered
October 14, 2020 - Study
The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support.
Citation Text:
Lown BA, Manning CF. The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-ce…