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  1. Psn-Pdf (pdf file)

    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…
  2. Spotlight (pdf file)

    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. …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33809/psn-pdf
    June 01, 2016 - In Conversation With… Gregg S. Meyer, MD, MSc June 1, 2016 In Conversation With… Gregg S. Meyer, MD, MSc. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc Editor's note: Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based system tha…
  4. Psn-Pdf (pdf file)

    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…
  5. psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx Spotlight Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities Source and Credits • This presentation is based on the March 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49678/psn-pdf
    March 01, 2013 - A Weighty Mistake March 1, 2013 Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/weighty-mistake Case Objectives Understand factors associated with weight-based dosing medication errors in pediatric populations. Describe how adoption of computerized provider order entry (CPOE) s…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49864/psn-pdf
    June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49508/psn-pdf
    January 01, 2007 - Language Barrier April 1, 2006 Flores G. Language Barrier. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/language-barrier The Case A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish- speaking parents when they noted that their daughter had generalized we…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33654/psn-pdf
    August 01, 2007 - In Conversation with...James L. Reinertsen, MD August 1, 2007 In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting firm …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863650/psn-pdf
    February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance Measurement Tracking, and Performance Feedback February 28, 2024 https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking- and-performance Summary To improve patient care and outcomes in the intensive care unit (ICU…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60172/psn-pdf
    March 01, 2021 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart Originally published on June 12, 2020 Last updated on January 11, 2021 https://psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly- reduc…
  12. psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
    January 01, 2024 - Spotlight Spotlight A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis 1 Source and Credits This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Garth Utter, MD, MSc, FACS…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72811/psn-pdf
    September 01, 2022 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors Originally published on March 3, 2021 Last updated on March 16, 2021 https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during- initial-treatment Summar…
  14. psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
    August 30, 2023 - Annual Perspective Impact of System Failures on Healthcare Workers George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD | March 21, 2023  View more articles from the same authors. Citation Text: Zangaro G, Van CM, Mossburg S. Imp…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847934/psn-pdf
    April 26, 2023 - Patient Safety Indicators April 26, 2023 Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/patient-safety-indicators Background Over the past 25 years, policymakers and providers, payers, and purchasers of health care have increasingly focused attention on pati…
  16. psnet.ahrq.gov/web-mm/other-side
    May 01, 2007 - SPOTLIGHT CASE The Other Side Citation Text: Vincent CA. The Other Side. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
  17. psnet.ahrq.gov/web-mm/communication-error-closed-icu
    July 01, 2016 - Communication Error in a Closed ICU Citation Text: Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…
  18. psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
    April 24, 2024 - The Danger of 10% Intravenous Calcium Chloride Extravasation. Citation Text: The Danger of 10% Intravenous Calcium Chloride Extravasation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Goog…
  19. psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
    January 03, 2017 - SPOTLIGHT CASE Treatment Challenges After Discharge Citation Text: Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar Bib…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867985/psn-pdf
    January 01, 2025 - Suicide Prevention March 25, 2025 Boudreaux E, Gale B, Mossburg SE. Suicide Prevention. PSNet [internet]. 20024. https://psnet.ahrq.gov/perspective/suicide-prevention Introduction Suicide is one of the leading causes of death in the United States, accounting for nearly 50,000 deaths in 2022, a 36% rise since 2000…

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