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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - Early in the career of
the freshly graduated physician, there are many things to learn and many mistakes
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psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - Help them to see how they will
benefit from a new way of doing things.
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psnet.ahrq.gov/web-mm/carpe-diem-seize-day
September 01, 2012 - Carpe Diem (Seize the Day)
Citation Text:
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/specimen-almost-lost
September 21, 2022 - Specimen Almost Lost
Citation Text:
Hehe YK. Specimen Almost Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Spotlight
Too Many Cooks in the Kitchen
Source and Credits
• This presentation is based on the August 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Richard P. Dutton, MD, MBA
o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - Infused, Not Ingested
November 1, 2005
Foley M. Infused, Not Ingested. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/infused-not-ingested
The Case
A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering
contrast, an unfamiliar task for this particular nurse. Rathe…
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety 101
Citation Text:
Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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D…
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psnet.ahrq.gov/periodic-issue/periodic-issue-402
August 30, 2023 - Commentary
The things we carry: the scope and impact of second victim syndrome.
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psnet.ahrq.gov/periodic-issue/periodic-issue-375
December 14, 2022 - Study
Bad things can happen: are medical students aware of patient centered care
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psnet.ahrq.gov/periodic-issue/periodic-issue-428
February 28, 2024 - organizations to focus both on eliminating errors (Safety I) and fostering resilience to understand how things
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - But when things generally go well, and when production pressure is routine, providers can become complacent
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - May 27, 2010
Doing the "right" things to correct wrong-site surgery.
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psnet.ahrq.gov/web-mm/techno-trip
May 01, 2005 - this one demonstrate that IT in health care requires more than simply adding "computerization" to make things
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - in phase 4, the whole team (referring and receiving) agrees on a patient plan and contingencies if things
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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - They are free lessons about how things go wrong and how
they can be fixed before someone gets hurt.
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psnet.ahrq.gov/web-mm/more-treatment-better-care
August 11, 2021 - antibiotics for sinusitis, routine chemistries ( 19 ) The Good Stewardship Working Group list of 5 things
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - Among other things, HSIB will look to build a skilled workforce combining health care risk managers,
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psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
October 26, 2022 - features or subsequent information refutes the hypothesis Availability The tendency to think that things
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psnet.ahrq.gov/web-mm/production-pressures
November 16, 2022 - January 20, 2021
Information flow during pediatric trauma care transitions: things falling
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - March 1, 2023
Information flow during pediatric trauma care transitions: things falling