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psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
August 01, 2006 - implement safe practices here in Massachusetts: reconciling medications and communicating critical test
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psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
March 01, 2019 - So suddenly the formulary changes, some biomedical equipment changes, a test or radiology reporting system
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psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
December 14, 2022 - Sarah Mossburg: It sounds like simulation really allows people to test adaptations to situations and
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psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
May 01, 2016 - patient, the context of the provider, time of day, geography, and then making a decision about the test
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psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
December 14, 2022 - Sarah Mossburg: It sounds like simulation really allows people to test adaptations to situations and
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psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
August 01, 2012 - relevant medical conditions, concurrent medications, potential drug interactions, and pertinent laboratory test
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psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
March 01, 2019 - So suddenly the formulary changes, some biomedical equipment changes, a test or radiology reporting system
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psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
April 24, 2024 - Demonstration, the CMS Innovation Center worked with select medical practices around the country to test
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psnet.ahrq.gov/node/836941/psn-pdf
April 27, 2022 - Demonstration, the CMS Innovation Center worked with select medical practices around the country to test
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong
Medication
September 30, 2020
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
The Case
A 65-year-old woman co…
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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/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - SPOTLIGHT CASE
Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture
Citation Text:
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room.
Citation Text:
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - Unseen Perils of Urinary Catheters
Citation Text:
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar Bib…
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX EndN…
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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 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx
Spotlight
A Missed Bowel Perforation – the Importance of
Diagnostic Reasoning
Source and Credits
• This presentation is based on the September 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/web…
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psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
March 30, 2020 - In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD
March 30, 2020
Also Read the Essay
Citation Text:
In Conversation With.. Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD. PSNet [internet]. 2020.In Conversation With... Ann Gaffey, RN, MS…
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psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
October 31, 2023 - SPOTLIGHT CASE
Robotic Surgery: Risks vs. Rewards
Citation Text:
Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Googl…
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psnet.ahrq.gov/node/867022/psn-pdf
October 30, 2024 - Delayed Symptomatic Subdural Hematoma Following an
Initially Normal CT Head
October 30, 2024
Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-h…
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psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Intraosseous Line Extravasation in a
Pediatric Trauma Patient
Source and Credits
• This presentation is based on the April 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: David Barnes, MD and Joseph Yoon, MD
o…