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psnet.ahrq.gov/node/33707/psn-pdf
February 01, 2011 - The University of Texas System Clinical Safety and
Effectiveness Course
February 1, 2011
Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and
Effectiveness Course. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv…
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psnet.ahrq.gov/node/33744/psn-pdf
February 01, 2013 - In Conversation With… Beverley H. Johnson
February 1, 2013
In Conversation With… Beverley H. Johnson. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
Editor's note: Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient-
and Family-…
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psnet.ahrq.gov/node/49584/psn-pdf
April 01, 2009 - EMR Entry Error: Not So Benign
April 1, 2009
Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
The Case
A 47-year-old man with advanced AIDS was admitted to an academic medical center with a chief complaint
of shortness of breath. He was …
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psnet.ahrq.gov/node/33849/psn-pdf
January 01, 2018 - In Conversation With… Robert Hirschtick, MD
January 1, 2018
In Conversation With… Robert Hirschtick, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
Editor's note: Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author
of a numbe…
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psnet.ahrq.gov/node/49437/psn-pdf
March 01, 2004 - Crossing the Line
March 1, 2004
Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/crossing-line
Case Objectives
Review complications of central venous catheterization
Discuss patient and operator factors that affect complication rates
Describe methods for preventing c…
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psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
September 01, 2017 - Missed Patient Assignment: Is Anyone There?
Citation Text:
Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
Copy Citation
Format:
Google …
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - If an MTP is activated, the blood bank can send a cooler with blood, FFP, and platelets in the appropriate
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - A couple of the key departments did not send representatives
and one member of the night staff was not
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psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
April 12, 2023 - The colleague secured a bed through the bed control department and suggested he send the patient over
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psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - "( 8 ) Providing feedback is a way to send critical messages to the recipient, e.g., "We are listening
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psnet.ahrq.gov/node/49807/psn-pdf
October 01, 2017 - He decided to send
a letter to ensure receipt of the results.
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Consider reversal of specific drugs such as opiates (check pupils), benzodiazepines,
anticholinergics
Send
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - association between prescription filling and his symptoms of nausea, sweating and irregular heartbeat, send
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psnet.ahrq.gov/node/49852/psn-pdf
February 01, 2019 - The colleague secured a bed through the bed control department
and suggested he send the patient over
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psnet.ahrq.gov/web-mm/translating-normal-abnormal
October 02, 2019 - He decided to send a letter to ensure receipt of the results.
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psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
February 26, 2025 - In Conversation With… Timothy B. McDonald, MD, JD
April 1, 2019
Citation Text:
In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy C…
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psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
March 01, 2012 - personally am not an advocate of this notion that you can put somebody through a half a day seminar and then send
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psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
March 01, 2012 - personally am not an advocate of this notion that you can put somebody through a half a day seminar and then send
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Andrew P.J. …
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psnet.ahrq.gov/node/73145/psn-pdf
April 28, 2021 - treatment by
saying how terrible our in-center units are, that's not really the message you want to send