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psnet.ahrq.gov/node/49642/psn-pdf
December 01, 2011 - Order Interrupted by Text: Multitasking Mishap
December 1, 2011
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
Case Objectives
State the prevalence of mobile devices among clinicians and their common health…
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psnet.ahrq.gov/node/842923/psn-pdf
February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric
Patient Complicating Cardiac Surgery and Bedside Chest
Closure.
February 1, 2023
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient
Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Failure to Rescue the Mother
Citation Text:
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote…
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psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
August 15, 2017 - Perils in Diagnosing a Stroke
Citation Text:
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
January 01, 2024 - Spotlight
Spotlight
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
1
Source and Credits
This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Garth Utter, MD, MSc, FACS…
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - SPOTLIGHT CASE
Missed Appendicitis
Citation Text:
Adams JG. Missed Appendicitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
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-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
Also Read the Essay
View more articles from the same authors.
Citation Text:
Savitz LA, S…
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Savitz LA, Sousane Z, Mossburg SE. Learning …
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psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
September 24, 2024 - initiatives and other areas of healthcare, could be a significant downside to pursuing zero harm, argues surgeon
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psnet.ahrq.gov/node/33752/psn-pdf
August 01, 2013 - RW: Johns Hopkins surgeon Martin Makary wrote a book in which, in part based on your work, he argued
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psnet.ahrq.gov/node/33878/psn-pdf
April 01, 2019 - say a heart condition, then went to a hospital to have heart surgery and the allegation was that
the surgeon
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psnet.ahrq.gov/node/72613/psn-pdf
December 22, 2020 - She is an oral surgeon by background and is
currently with UCSF School of Dentistry.
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - The caricature is the surgeon having a tantrum in the
OR and throwing instruments.
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psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
June 01, 2017 - I'm told that if you start your first consultant post in a hospital as a surgeon, you almost invariably
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psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - September 4, 2024
Surgeon and surgical trainee experiences after adverse patient events
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psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - and Chronic Health Evaluation II), and the MPI (Mannheim Peritonitis Index).23
• Ultimately, the surgeon
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psnet.ahrq.gov/node/33686/psn-pdf
August 01, 2009 - As I was finishing my doctorate, a surgeon appeared in my office and said, "You may not know it, but
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psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
February 26, 2025 - say a heart condition, then went to a hospital to have heart surgery and the allegation was that the surgeon
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psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
April 26, 2023 - The caricature is the surgeon having a tantrum in the OR and throwing instruments.