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psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
February 01, 2012 - An Untimely End Despite End-of-Life Care Planning
Citation Text:
Elia G, Barbour S, Anderson WG. An Untimely End Despite End-of-Life Care Planning. 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/web-mm/easily-forgotten-tube
June 01, 2016 - An Easily Forgotten Tube
Citation Text:
Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
February 01, 2012 - Febrile Neutropenia and an Almost Fatal Medication Error
Citation Text:
Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. 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/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable
Citation Text:
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
October 27, 2021 - Study
Classic
Hospital board and management practices are strongly related to hospital performance on clinical quality metrics.
Citation Text:
Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performanc…
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psnet.ahrq.gov/innovation/awareness-human-factors-operating-theatres-during-covid-19-pandemic
January 13, 2021 - EMERGING INNOVATIONS
Awareness of human factors in the operating theatres during the COVID-19 pandemic
Citation Text:
Britton CR, Hayman G, Stroud N. Awareness of Human Factors in the operating theatres during the COVID-19 pandemic. Journal of Perioperative Practice. 2020;31(1-2). doi:10.1177/1750…
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psnet.ahrq.gov/innovation/esimpler-dynamic-electronic-health-record-integrated-checklist-clinical-decision-support
June 16, 2021 - EMERGING INNOVATIONS
eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.
Citation Text:
Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support duri…
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psnet.ahrq.gov/issue/do-junior-doctors-make-more-prescribing-errors-experienced-doctors-when-prescribing
February 22, 2023 - Study
Do junior doctors make more prescribing errors than experienced doctors when prescribing electronically using a computerised physician order entry system combined with a clinical decision support system? A cross-sectional study.
Citation Text:
Kalfsvel L, Wilkes S, van der Kuy H, e…
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psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal-mental-health
March 29, 2023 - who have been pregnant or were pregnant shows very clearly that suicidality and mental health are the responsibility
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - timely manner when they lack knowledge or experience, have ineffective communication or diffusion of responsibility
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psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
November 27, 2023 - It is their responsibility to speak up when they see something.
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psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
November 27, 2023 - It is their responsibility to speak up when they see something.
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psnet.ahrq.gov/perspective/adverse-events-dentistry
December 22, 2020 - Adverse Events in Dentistry
December 22, 2020
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Kalenderian E, Walji MF, Fitall E, et al. Adverse Events in Dentistry. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
December 27, 2019 - Cultural Competence and Patient Safety
December 27, 2019
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - Getting Into Patient Safety: A Personal Story
Jeffrey B. Cooper, PhD | August 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx
Spotlight
A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion
Source and Credits
• This presentation is based on the July 2023 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
April 26, 2023 - In Conversation With… Mark Chassin, MD, MPP, MPH
April 1, 2017
Citation Text:
In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/deadly-duo
April 28, 2021 - The Deadly Duo
Citation Text:
Maldonado JR. The Deadly Duo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Intraoperative Awareness during Rhinoplasty
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: Christian Bohringer MBBS and Jaijeet Toor MD
AHRQ WebM&M Edit…
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psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
August 14, 2024 - SPOTLIGHT CASE
Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.
Citation Text:
Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…