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psnet.ahrq.gov/node/865454/psn-pdf
March 27, 2024 - Ensuring Patient and Workforce Safety Culture in
Healthcare
March 27, 2024
Murray J, Sorra J, Gale B, et al. Ensuring Patient and Workforce Safety Culture in Healthcare. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
Introduction
In 2020, the I…
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psnet.ahrq.gov/node/50614/psn-pdf
October 30, 2019 - In Conversation With… Vineet Chopra, MD, MSc
October 30, 2019
In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
Editor's note: Dr. Chopra is Chief of the Division of Hospital Medicine and Associate Professor of
Medicine at the…
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - • An orthopedic surgeon was consulted and recommended closed reduction
of the left hip in the ED. … ”
• The orthopedic surgeon performed the hip reduction successfully.
7
Case Details (4)
• The
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psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me
May 01, 2019 - Electrocardiogram Results: ***READ ME***
Citation Text:
Alpert JS. Electrocardiogram Results: ***READ ME***. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XM…
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psnet.ahrq.gov/node/49574/psn-pdf
November 01, 2008 - A Mid-Summer Fog
November 1, 2008
Braddock CH. A Mid-Summer Fog. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mid-summer-fog
The Case
A 33-year-old woman with type I diabetes mellitus was admitted for symptoms of left flank pain, dysuria,
and emesis, concerning for pyelonephritis. The patient was taking …
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psnet.ahrq.gov/node/49770/psn-pdf
September 01, 2016 - Wrong-Time Error With High-Alert Medication
September 1, 2016
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
The Case
A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - SPOTLIGHT CASE
Fatal Error in Neonate: Does "Just Culture" Provide an Answer?
Citation Text:
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.461_slideshow.ppt
November 01, 2018 - Spotlight
Spotlight
Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees
*
Source and Credits
This presentation is based on the November 2018 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Olle ten C…
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psnet.ahrq.gov/node/49413/psn-pdf
September 01, 2003 - Did We Forget Something?
September 1, 2003
Gibbs VC. Did We Forget Something? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/did-we-forget-something
The Case
A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially
attributed to ventilator-associated pneumo…
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psnet.ahrq.gov/web-mm/communication-consultants
October 01, 2018 - Communication With Consultants
Citation Text:
Cohn SL. Communication With Consultants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
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psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - In Conversation With… Vineet Chopra, MD, MSc
October 30, 2019
Citation Text:
In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation…
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health
Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for
Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - The surgeon had already destroyed two of these devices, and there was only one left in the whole OR suite
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psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
November 01, 2018 - the hospital—patients rarely know their emergency medicine physician, their anesthesiologist, their surgeon … Under the Obama Administration, Medicare's top physician leader and the Surgeon General were both hospitalists
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psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
November 01, 2018 - the hospital—patients rarely know their emergency medicine physician, their anesthesiologist, their surgeon … Under the Obama Administration, Medicare's top physician leader and the Surgeon General were both hospitalists
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - November 8, 2017
Surgeon-reported conflict with intensivists about postoperative goals … July 3, 2014
The role of surgeon error in withdrawal of postoperative life support.
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psnet.ahrq.gov/web-mm/check-wristband
August 03, 2009 - don't know just how far this mistake would have gone, because the patient is frequently asleep when the surgeon
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psnet.ahrq.gov/node/49606/psn-pdf
August 01, 2010 - with diabetes mellitus, hypertension, and obstructive sleep apnea (OSA) was referred to
an orthopedic surgeon
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - A cardiovascular surgeon was consulted that day, and bypass surgery was scheduled for 4 days later.
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psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - cannot lie flat for the operation while breathing spontaneously, as is required for the ophthalmic surgeon