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psnet.ahrq.gov/node/840256/psn-pdf
November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole
Werner, PhD
November 16, 2022
In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
Editor’s note: Dr. Pascale Carayon, PhD, is a p…
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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - SPOTLIGHT CASE
Cognitive Overload in the ICU
Citation Text:
Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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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…
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM
April 1, 2018
In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and
Directo…
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psnet.ahrq.gov/node/50754/psn-pdf
December 18, 2019 - "Do You Want Everything Done?": Clarifying Code Status
December 18, 2019
Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
Disclosure of Relevant Financial Relationships: As a p…
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psnet.ahrq.gov/node/33828/psn-pdf
March 01, 2017 - In Conversation With… Mary Dixon-Woods, DPhil
March 1, 2017
In Conversation With… Mary Dixon-Woods, DPhil. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
Editor's note: Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University
and Deputy …
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
June 28, 2023
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue
Necrosis and Cuff Rupture. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…
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psnet.ahrq.gov/node/33826/psn-pdf
February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM
February 1, 2017
In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
Editor's note: Dr. Edmondson is professor of Leadership and Management at Harvard Business School.
Her la…
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psnet.ahrq.gov/node/49723/psn-pdf
January 01, 2015 - Monitoring Fetal Health
January 1, 2015
Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/monitoring-fetal-health
Case Objectives
Define fetal heart rate monitoring.
Describe the current state of evidence regarding fetal heart rate monitoring.
List the known …
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - In Conversation With… Mark Chassin, MD, MPP, MPH
April 1, 2017
In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
Editor's note: Dr. Chassin is president and chief executive officer of The Joint Commission. He is also
p…
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psnet.ahrq.gov/node/33783/psn-pdf
April 01, 2015 - In Conversation With… Lucian Leape, MD
April 1, 2015
In Conversation With… Lucian Leape, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-lucian-leape-md
Editor's note: Dr. Lucian Leape is Adjunct Professor of Health Policy at the Harvard School of Public
Health, Chairman of the Lucian …
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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx
Spotlight
Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/…
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation
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August 30, 2023
View more articles from the…
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - SPOTLIGHT CASE
Don't Dismiss the Dangerous: Obstetric Hemorrhage
Citation Text:
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - SPOTLIGHT CASE
Another Fall
Citation Text:
Bogardus SG. Another Fall. 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/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
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May 29, 2024
View more articles from the same authors.
Inno…
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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - SPOTLIGHT CASE
Unintended Consequences of CPOE
Citation Text:
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. 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/web-mm/anemia-and-delayed-colon-cancer-diagnosis
July 21, 2020 - SPOTLIGHT CASE
Anemia and Delayed Colon Cancer Diagnosis
Citation Text:
Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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