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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
September 27, 2023 - SPOTLIGHT CASE
Missed Opportunities for Suicide Risk Assessment
Citation Text:
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - The Impact of Communication on Medication Errors
Citation Text:
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
October 02, 2024 - Safety I, Safety II, and the New Views of Safety
Citation Text:
Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety
Jane Ball, PhD, and Peter Griffiths, PhD | March 1, 2018
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Citation Text:
Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient…
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case
Citation Text:
Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US …
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psnet.ahrq.gov/web-mm/departure-central-line-ritual
October 13, 2018 - Departure From Central Line Ritual
Citation Text:
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. 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/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance
Lance L. Roberts, MS; Marcia M. Ward, PhD; Thomas C. Evans, MD | April 1, 2010
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psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
February 01, 2012 - Balancing Supervision and Autonomy: An Ongoing Tension
C. Jessica Dine, MD, MA; and Jennifer S. Myers, MD | February 1, 2012
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Citation Text:
Dine JC, Myers JS. Balancing Supervision and Autonomy:…
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psnet.ahrq.gov/node/74120/psn-pdf
November 30, 2021 - Culture Clash No More: Integration and Coordination of
Disease Treatment and Palliative Care
November 30, 2021
Spero H, Usher AE, Howard B, et al. Culture Clash No More: Integration and Coordination of Disease
Treatment and Palliative Care . PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/culture-clash-no-mo…
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psnet.ahrq.gov/node/837913/psn-pdf
August 31, 2022 - Miscommunication During the Interhospital Transport of a
Critically Ill Child
August 31, 2022
Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-c…
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - When the Meds Don’t Reach the Bed
Citation Text:
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/838220/psn-pdf
September 27, 2019 - Primary Care and Patient Safety: Opportunities at the
Interface
September 28, 2022
O’Malley P, McNellis B, Chew E, et al. Primary Care and Patient Safety: Opportunities at the Interface.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
Editor’s Not…
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psnet.ahrq.gov/node/60363/psn-pdf
March 01, 2021 - Transition Coaches® Reduce Readmissions for Medicare
Patients With Complex Postdischarge Needs
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-
postdischarge-needs
Summary
Under a program kn…
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - Miscommunication During the Interhospital Transport of a Critically Ill Child
Citation Text:
Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human …
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psnet.ahrq.gov/perspective/conversation-james-augustine-md
July 28, 2021 - KH: How do you start training people to use these other technologies in the delivery of care?
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Communication Error in a Closed ICU
Citation Text:
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/60744/psn-pdf
July 29, 2020 - The NSTEMI Curbside Consultation
July 29, 2020
Villablanca AC, Wong GX. The NSTEMI Curbside Consultation. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for
Continuing Medical E…
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psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
February 01, 2014 - In Conversation With… Richard Kronick, PhD
February 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Richard Kronick, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…
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psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH
April 1, 2009
Also Read an Essay
Citation Text:
In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009.In Conversation with...Mark Chassin, MD, MPP, MPH . PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
January 01, 2021 - Spotlight
Spotlight
Culture Clash No More:
Integration and Coordination of Disease
Treatment and Palliative Care
Source and Credits
• This presentation is based on the November 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Han…