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psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
January 13, 2010 - SPOTLIGHT CASE
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
Citation Text:
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/node/848124/psn-pdf
April 26, 2023 - during surgery, even if the patient’s blood pressure had gone down a little bit, I
wouldn’t yell at the surgeon
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psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
June 01, 2011 - a certain number of hours for proficiency and that can produce significantly better results if the surgeon
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psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
February 26, 2025 - of OpenNotes, telling me the story of the patient who was keeping his own notebook and said to the surgeon
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psnet.ahrq.gov/node/33866/psn-pdf
September 01, 2018 - of OpenNotes, telling me the story of the patient who was
keeping his own notebook and said to the surgeon
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - a certain number of hours for proficiency and that can produce significantly better results if the surgeon
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Intubation Mishap
September 1, 2003
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/intubation-mishap
Case Objectives
To understand and apply a structured method of human factors case analysis
To describe the key components of effective teamwork
To understand the imp…
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - Annual Perspective
Ensuring Patient and Workforce Safety Culture in Healthcare
John Murray, Joann Sorra, Bryan Gale, Sarah Mossburg
| March 27, 2024
View more articles from the same authors.
Citation Text:
Murray J, Sorra J, Gale B, et al. Ensuring Patient…
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - SPOTLIGHT CASE
What Happened on Telemetry?
Citation Text:
Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNo…
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - The Impact of Communication on Medication Errors
March 15, 2021
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors
The Case
A 93-year-old man with a history of chronic systolic heart failure…
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx
Spotlight
Overdose of Gabapentin and Oxycodone in a Patient
with End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotl…
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psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - In Conversation With... Anjali Joseph, PhD, EDAC and
Molly M. Scanlon, PhD, FAIA, FACHA
June 30, 2021
In Conversation With.. Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-
…
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psnet.ahrq.gov/node/836879/psn-pdf
April 27, 2022 - In Conversation With... Michael L. Millenson
April 27, 2022
In Conversation With.. Michael L. Millenson. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-michael-l-millenson
December 16, 2021
Editor’s note: Michael L. Millenson is the President of Health Quality Advisors LLC, author of the c…
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psnet.ahrq.gov/node/850673/psn-pdf
June 14, 2023 - Surgeon
General to develop a standard of care in pediatrics.
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psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
August 01, 2007 - I know a hospital where the biggest trauma surgeon in the region had his privileges to do surgery and
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psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
July 01, 2006 - A surgeon along with an anesthesiologist would be beneficial if you were working on a project related
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
February 01, 2013 - recommendations—such as admonitions to bring an updated medication list to your doctor's appointments, make sure the surgeon
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psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
July 01, 2006 - A surgeon along with an anesthesiologist would be beneficial if you were working on a project related
-
psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
August 01, 2007 - I know a hospital where the biggest trauma surgeon in the region had his privileges to do surgery and
-
psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - SPOTLIGHT CASE
Intubation Mishap
Citation Text:
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote …