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psnet.ahrq.gov/node/33837/psn-pdf
July 01, 2017 - In Conversation With… Michelle Mello, MPhil, JD, PhD
July 1, 2017
In Conversation With… Michelle Mello, MPhil, JD, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
Editor's note: Michelle Mello is Professor of Law at Stanford Law School and Professor of Healt…
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psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD
August 1, 2012
In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
Editor's note: The topic of patient safety in long-term care facilities has not received the attent…
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - Missed CANDOR Implementation Opportunities.
Citation Text:
Schweitzer L. Missed CANDOR Implementation Opportunities.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/transfusion-overload
September 23, 2020 - SPOTLIGHT CASE
Transfusion Overload
Citation Text:
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - SPOTLIGHT CASE
False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.
Citation Text:
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …
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psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
November 13, 2024 - SPOTLIGHT CASE
Abdominal Pain in Early Pregnancy
Citation Text:
Kilpatrick CC. Abdominal Pain in Early Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49771/psn-pdf
July 01, 2016 - Unintended Consequences of CPOE
October 1, 2016
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
Case Objectives
Explain how technology, including computerized provider order entry, can transform, rather than
eliminate, hazards.
Recogni…
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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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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/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…
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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/33764/psn-pdf
April 01, 2014 - In Conversation With… Tejal K. Gandhi, MD, MPH
April 1, 2014
In Conversation With… Tejal K. Gandhi, MD, MPH. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
Editor's note: Tejal K. Gandhi, MD, MPH, CPPS, is an Associate Professor of Medicine at Harvard
Medical School …
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - They need help in developing communication skills beyond the cell phone and texts, to talk to and collaborate
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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - They need help in developing communication skills beyond the cell phone and texts, to talk to and collaborate
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - Measuring Patient Safety
Michelle Schreiber, MD; Cindy Van, MHSA; Sarah E. Mossburg, RN, PhD
| December 14, 2022
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Schreiber M, Van C, Mossburg SE. Measuring Patient Safety. PSN…
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety
December 14, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Dr. Michelle Schreiber on Measuring Patient Safety. PSNet [internet]. 2022.In Conversation With... Dr. Michelle …
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - wild dream or not, but
there was nothing like an autopsy to sensitize you to the limitations of our skills
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - Resources Used and Skills Needed
Staffing: Total staffing for the program is approximately 120 paid