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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by:…
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psnet.ahrq.gov/node/33788/psn-pdf
June 01, 2015 - In Conversation With… Christine Cassel, MD
June 1, 2015
In Conversation With… Christine Cassel, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-christine-cassel-md
Editor's note: Christine Cassel, MD, is President and CEO of the National Quality Forum (NQF). Dr.
Cassel, one of the foun…
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - The Result Stopped Here
June 1, 2004
Astion ML. The Result Stopped Here. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/result-stopped-here
The Case
A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital
for continued wound care and intravenous (IV) antib…
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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - The Case of Mistaken Intubation
June 1, 2016
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/case-mistaken-intubation
Case Objectives
Appreciate that most older adults and many younger chronically ill patients have discussed or
documented their preferences for l…
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psnet.ahrq.gov/clinical-areas
March 24, 2025 - Clinical Areas
Scroll down to search or browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nurse care or medical specialty, featured in the resources.
Latest by Clinical Areas
In Conversation with Edwin Boudreaux about S…
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psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - Harm From Alarm Fatigue
December 1, 2015
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/harm-alarm-fatigue
Case Objectives
Define alarm fatigue and describe potential errors that can occur due to alarm fatigue.
Identify federal and national agencies focusing on …
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - Patient Safety Indicators
Citation Text:
Tokareva I, Romano P. Patient Safety Indicators.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
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psnet.ahrq.gov/web-mm/managing-care-challenges-group-home-setting-staffing-adequate-unplanned-incidents
April 27, 2022 - Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?
Citation Text:
Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/web-mm/wrongful-resuscitation
October 12, 2012 - The Wrongful Resuscitation
Citation Text:
Teno JM. The Wrongful Resuscitation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
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psnet.ahrq.gov/node/33792/psn-pdf
September 01, 2015 - You think about the physician who has advanced
knowledge and skills and training trying to wade through
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psnet.ahrq.gov/node/863649/psn-pdf
February 28, 2024 - update to fully support
healthcare teams and continue to improve their collaboration and communication skills
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - for high-risk procedures or for the use of high-risk drugs;
There was poor staff/trainee teamwork skills
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psnet.ahrq.gov/node/50754/psn-pdf
December 18, 2019 - Other clinical skills are certainly important, but these conversations around
advance care planning
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psnet.ahrq.gov/node/33828/psn-pdf
March 01, 2017 - And there is this sense that it's in that category of things like communication skills and
other things
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psnet.ahrq.gov/node/33826/psn-pdf
February 01, 2017 - But now they had to
figure out how to work together across diverse skills and areas of expertise over
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - standardized algorithms to assess post-intubation hypoxia, and simulation training to improve intubation skills
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psnet.ahrq.gov/node/60267/psn-pdf
March 01, 2021 - Resources Used and Skills Needed
Staffing: For every 70-100 person panel of program participants, each
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - distention, masses, and scars
EM physicians and general surgeons especially should strive to master their skills
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - natural,
habitual, and preferred way(s) of absorbing, processing, and retaining new information and skills
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - Resources Used and Skills Needed
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