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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
October 01, 2003 - Spotlight Case [MONTH] 2003
Spotlight Case October 2003
Hemivulvectomy:
Wrong Side Removed
Source and Credits
This presentation is based on the Oct. 2003
AHRQ WebM&M Spotlight Case in OB/GYN
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Charles Vin…
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psnet.ahrq.gov/node/33612/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—I. The Dana-Farber Cancer Institute Experience
May 1, 2005
Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber
Cancer Institute Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/organizat…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Bad Writing, Wrong Medication
*
*
Source and Credits
This presentation is based on the April 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Beth Devine, PharmD, MBA, PhD
University of Washingto…
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psnet.ahrq.gov/node/49800/psn-pdf
July 01, 2017 - The Hidden Harms of Hand Sanitizer
July 1, 2017
Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
The Case
A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital
for community-acquired pn…
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psnet.ahrq.gov/node/49499/psn-pdf
December 02, 2020 - An Outpatient 'Zebra'
January 1, 2006
Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/outpatient-zebra
The Case
A 64-year-old man presented to the outpatient clinic with a chief complaint of left foot pain and numbness.
His past medical history included lumbar disc diseas…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.191_slideshow.ppt
January 01, 2009 - Spotlight Case July 2008
Spotlight Case January 2009
To Transfer or Not to Transfer
Source and Credits
This presentation is based on the January 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jesse M. Pines, MD, MBA, MSCE
University o…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
May 01, 2011 - Spotlight Case July 2008
Spotlight Case
Duty to Disclose Someone Else’s Error
*
*
Source and Credits
This presentation is based on the May 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Thomas H. Gallagher, MD University of Washington
…
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psnet.ahrq.gov/node/866055/psn-pdf
May 29, 2024 - proven to improve patient
outcomes.3 Because of this, Ascension Data Science Institute has heavily supported … Ascension supported this by creating a campaign to improve psychological safety.
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psnet.ahrq.gov/node/33588/psn-pdf
March 15, 2025 - In the study, most clinicians felt unsupported or
under-supported, partly due to ambiguity around whom
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psnet.ahrq.gov/primer/culture-safety
September 15, 2024 - determining the values, beliefs, norms, and behaviors related to patient safety that are rewarded, supported
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - hemoglobin was still above the restrictive hemoglobin transfusion threshold of 7.0 g/dL (which has been supported … While restricted transfusion is supported by the literature and has been incorporated into guidelines
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psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - Strategic decisions, supported by resources, must then follow this belief. … Organizational resources should be focused on ensuring that work settings are supported in these efforts
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psnet.ahrq.gov/node/50610/psn-pdf
October 30, 2019 - Despite being an expected part of NICU care, such routine interventions may not be
supported by evidence
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psnet.ahrq.gov/node/72616/psn-pdf
December 22, 2020 - patient errors, hard tissue damage, and soft
tissue damage.7 As noted in the study conclusions and supported
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - A consensus statement supported by multiple international professional societies including the American … June 29, 2011
Risks in the analogue and digitally-supported medication process and potential
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psnet.ahrq.gov/node/49588/psn-pdf
August 01, 2009 - psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
supported … In this specific case, it appears that the nursing staff members were not supported in making difficult
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
October 01, 2008 - migrant and farm workers to the health system through a personal health record and identification system supported
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psnet.ahrq.gov/node/33801/psn-pdf
February 01, 2016 - If
physicians are really happy about their work, enjoying their work, and well supported in their work … that study "In Search of Joy in Practice," because I wasn't certain whether we would
find things that supported
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.143_slideshow.ppt
January 01, 2015 - Provider-Centered Care
Many current systems seem designed to meet needs of providers rather than patients, supported
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psnet.ahrq.gov/node/33830/psn-pdf
March 22, 2016 - every year in the US due to medical errors, these estimates rely
on flawed methodology and are not supported