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1381. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
      November 01, 2005 - senior leadership support Secure commitment for resources for the project during its development Start

1382. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861838/psn-pdf
      January 31, 2024 - Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling January 31, 2024 https://psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling Summary Adverse events resulting from medications are a common occurrence that often go undetected, unreported, and unaddressed.1 The imp…

1383. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33649/psn-pdf
      May 01, 2007 - And I did start to challenge these doctors' colleagues, who were usually protecting their associates … Then we can start to highlight areas where things are getting better.

1384. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73229/psn-pdf
      May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities May 26, 2021 Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…

1385. Antiseizure Medication Disorder | PSNet
      psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
      April 01, 2006 - SPOTLIGHT CASE Antiseizure Medication Disorder Citation Text: Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX En…

1386. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860399/psn-pdf
      January 24, 2024 - Best Practices for Administering SOPS Surveys. January 10, 2024 Agency for Healthcare Research and Quality. January 24, 2024. https://psnet.ahrq.gov/issue/best-practices-administering-sops-surveys Patient safety culture survey projects can yield important learnings if done correctly. The webinar detailed best prac…

1387. July Syndrome | PSNet
      psnet.ahrq.gov/web-mm/july-syndrome
      July 01, 2011 - various members of the interprofessional team during the transition, and the implementation of staggered start

1388. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33696/psn-pdf
      June 01, 2010 - If you start from the position that you're looking for aberrant presentations, or if you're aware of … PC: You must have a bit of a thick skin to start that.

1389. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33806/psn-pdf
      April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH April 1, 2016 In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of Pediatrics a…

1390. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49732/psn-pdf
      May 01, 2015 - Errors in Sepsis Management May 1, 2015 Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/errors-sepsis-management Case Objectives Define sepsis, severe sepsis, and septic shock. Describe the severe sepsis/septic shock resuscitation bundle. Recognize commonly encou…

1391. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60737/psn-pdf
      July 29, 2020 - Second victim support programs for healthcare organizations. July 29, 2020 Stone M. Second victim support programs for healthcare organizations. Nurs Manage. 2020;51(6):38-45. https://psnet.ahrq.gov/issue/second-victim-support-programs-healthcare-organizations This literature review describes the types of second v…

1392. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33765/psn-pdf
      April 01, 2014 - We start from the premise that we want to move the system forward. … Over the next year, we will start to see periods of time covered in the safety score that weren't covered … So that will enable us to start to see if there were trends of change in the wake of our score.

1393. In Conversation With… Amy J. Starmer, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
      May 31, 2023 - In Conversation With… Amy J. Starmer, MD, MPH April 1, 2016  Citation Text: In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation …

1394. Can Research Help Us Improve the Medical Liability System? | PSNet
      psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
      March 01, 2012 - Once you start taking control and feel that you're in control over that question, it actually brings … So the next frontier is to start to take a hard look at those because we don't have excuses anymore. … In that conversation I slid a legal pad across the table and I said, "Write them down and I'll start … We need to be robust enough to start asking those harder questions if we're going to make a difference … If we can start to ease the fear a little bit and openly, honestly in these dialogues, then we'll get

1395. In Conversation With… Richard C. Boothman, JD | PSNet
      psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
      March 01, 2012 - Once you start taking control and feel that you're in control over that question, it actually brings … So the next frontier is to start to take a hard look at those because we don't have excuses anymore. … In that conversation I slid a legal pad across the table and I said, "Write them down and I'll start … We need to be robust enough to start asking those harder questions if we're going to make a difference … If we can start to ease the fear a little bit and openly, honestly in these dialogues, then we'll get

1396. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33791/psn-pdf
      September 01, 2015 - I think we will start to unveil some national data around that. … You would never start with yesterday's note as a template for the assessment and plan because it's too … We have to start teaching our residents to let go of some information and reteach them to synthesize

1397. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49571/psn-pdf
      October 01, 2008 - Coming Up Short October 1, 2008 Hochberg Z'ev. Coming Up Short. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/coming-short The Case A 12-year-old Hispanic female was seen for a well-child check. The child was delivered 2 months prematurely (likely due to domestic violence) in Puerto Rico. She had an intra…

1398. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38477/psn-pdf
      October 03, 2017 - Serious Adverse Events Reports. October 3, 2017 The Quality Improvement Committee. Wellington, New Zealand; 2006-2013. https://psnet.ahrq.gov/issue/serious-adverse-events-reports Considered a starting point for a national reporting initiative, this series of annual reports provides statistics on serious and sentin…

1399. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33642/psn-pdf
      November 01, 2006 - In Conversation With...Donald A. Norman, PhD November 1, 2006 In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you become interested…

1400. Errors in Sepsis Management | PSNet
      psnet.ahrq.gov/web-mm/errors-sepsis-management
      November 03, 2015 - SPOTLIGHT CASE Errors in Sepsis Management Citation Text: Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X…