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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…
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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.
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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.
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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
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - for people to understand the history of learning health systems because this
kind of work did not start
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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…
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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…
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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.
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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.
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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
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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
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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
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psnet.ahrq.gov/node/50878/psn-pdf
February 05, 2020 - The role of racism as a core patient safety issue.
February 5, 2020
Feeley D, Torres T. The role of racism as a core patient safety issue. Healthcare Executive. 2020;35(1):58-
61.
https://psnet.ahrq.gov/issue/role-racism-core-patient-safety-issue
A variety of biases can reduce the effectiveness and safety of care.…
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psnet.ahrq.gov/node/853075/psn-pdf
August 30, 2023 - Striving for diagnostic excellence.
August 30, 2023
Centor RM, Dhaliwal G. Annals On Call. July 2023.
https://psnet.ahrq.gov/issue/striving-diagnostic-excellence
Diagnostic accuracy requires both cognitive and team-focused skill development. This podcast interview
shares problem-solving tactics that support diagno…
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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…
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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…
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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…
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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…
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psnet.ahrq.gov/node/43591/psn-pdf
August 02, 2015 - The automated operating room: a team approach to
patient safety and communication.
August 2, 2015
Nissan J, Campos V, Delgado H, et al. The automated operating room: a team approach to patient safety
and communication. JAMA Surg. 2014;149(11):1209-10. doi:10.1001/jamasurg.2014.1825.
https://psnet.ahrq.gov/issue/au…
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psnet.ahrq.gov/node/42534/psn-pdf
August 28, 2013 - Risk factors for hospital admissions associated with
adverse drug events.
August 28, 2013
Kongkaew C, Hann M, Mandal J, et al. Risk factors for hospital admissions associated with adverse drug
events. Pharmacotherapy. 2013;33(8):827-37. doi:10.1002/phar.1287.
https://psnet.ahrq.gov/issue/risk-factors-hospital-admi…