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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/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/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…
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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/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/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/846915/psn-pdf
March 29, 2023 - Challenging Case of Multiple Suicide Attempts in a
Complex Patient with Psychiatric Comorbidities.
March 29, 2023
Bourgeois JA, Xiong G. Challenging Case of Multiple Suicide Attempts in a Complex Patient with
Psychiatric Comorbidities. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/challenging-case-multiple…
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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/node/49840/psn-pdf
September 01, 2018 - Steroids and Safety: Preventing Medication Adverse
Events During Transitions of Care
September 1, 2018
Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of
Care. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adver…
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psnet.ahrq.gov/node/60220/psn-pdf
April 29, 2020 - Communication skills and error in the intensive care unit.
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - Psychiatrists working in graduate medical education may face the dilemma of needing to give trainees knowledge, 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/851971/psn-pdf
July 31, 2023 - Transferring information efficiently requires practice; it has been proposed that clinical
handover skills
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psnet.ahrq.gov/node/865373/psn-pdf
March 27, 2024 - a cognitive assistant for radiologists who are
looking at imaging to complement their considerable skills
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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/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/node/866993/psn-pdf
October 30, 2024 - Some interventions show promise across
multiple substances—for example, prevention strategies like skills-based
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psnet.ahrq.gov/node/846975/psn-pdf
March 28, 2023 - years, we partnered with AHRQ on the development of materials focused on team-based communication
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