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psnet.ahrq.gov/node/33789/psn-pdf
August 01, 2015 - world in which patients are managing a lot of
their own care, or nonphysicians with the appropriate skills
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - EM physicians and general surgeons especially
should strive to master their skills as diagnosticians
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - Sleep deprivation in resident physicians in hospitals has been associated with impaired psychomotor skills
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - consequently, they may not buy in to the importance of following the care plan or lack the knowledge or skills
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psnet.ahrq.gov/node/74226/psn-pdf
February 01, 2019 - Resources Used and Skills Needed
VHA support for implementation includes training, technical assistance
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psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
April 24, 2024 - even on a shift-by-shift basis depending on the availability of other staff and the mix of nursing skills
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psnet.ahrq.gov/web-mm/getting-root-matter
September 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/web-mm/impact-communication-medication-errors
August 01, 2009 - natural, habitual, and preferred way(s) of absorbing, processing, and retaining new information and skills
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psnet.ahrq.gov/primer/maternal-safety
January 10, 2024 - August 22, 2018
Didactic and simulation nontechnical skills team training to improve
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - EM physicians and general surgeons especially should strive to master their skills as diagnosticians
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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - even on a shift-by-shift basis depending on the availability of other staff and the mix of nursing skills
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psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - November 30, 2016
Nurses' perceived skills and attitudes about updated safety concepts
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - SPOTLIGHT CASE
Crossing the Line
Citation Text:
Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - SPOTLIGHT CASE
The Case of Mistaken Intubation
Citation Text:
Silveira MJ. The Case of Mistaken Intubation. 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/perspective/conversation-thomas-j-nasca-md-macp
July 10, 2024 - In Conversation With… Thomas J. Nasca, MD, MACP
April 1, 2016
Citation Text:
In Conversation With… Thomas J. Nasca, MD, MACP. 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/node/74713/psn-pdf
January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking
January 26, 2022
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
Disclosure of Relevant Financial Relationships: As a provider ac…
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Patient Safety Events Involving Opioid
Dose Stacking
Source and Credits
• This presentation is based on the January 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: Hollie Porras, PharmD, BCPS and Cathy Lammers…
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psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
April 01, 2008 - Anticoagulation: Held Too Long
Citation Text:
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - Missed CANDOR Implementation Opportunities.
November 16, 2022
Schweitzer L. Missed CANDOR Implementation Opportunities. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
The Case
A 58-year-old man with a history of type 2 diabetes mellitus, hypertension, morbid obesit…