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  1. Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
    January 01, 2023 - The Vortex: a universal “high-acuity implementation tool” for emergency airway management.

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49708/psn-pdf
    May 01, 2014 - Medication Reconciliation With a Twist (or Dare We Say, a Patch?) May 1, 2014 Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch Case Objectives Appreciate that medication discrepanc…

  3. In Conversation With… Shantanu Agrawal, MD, MPhil | PSNet

    psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
    February 26, 2025 - In Conversation With… Shantanu Agrawal, MD, MPhil September 1, 2019  Citation Text: In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Co…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49738/psn-pdf
    August 21, 2015 - Privacy or Safety? August 21, 2015 Halamka JD, McGraw D. Privacy or Safety? PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/privacy-or-safety Case Objectives Understand that the HIPAA Omnibus Rule is an enabler of data sharing, not a barrier. Review common misconceptions about privacy rules. Understand the…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49615/psn-pdf
    December 01, 2010 - The Forgotten Turn December 1, 2010 Barbour S. The Forgotten Turn. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/forgotten-turn Case Objectives Describe the six stages of pressure ulceration per the National Pressure Ulcer Advisory Panel. List risk factors for the development of pressure ulcers in hospita…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33784/psn-pdf
    April 01, 2015 - A surgeon could believe that it is a good tool; it might improve communication.

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33607/psn-pdf
    September 27, 2022 - Burnout September 27, 2022 Yellowlees P, Rea M. Burnout. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/burnout Originally published in December 2011 by researchers at the University of California, San Francisco. Updated in September 2022 by Peter Yellowlees, MD and Margaret Rea, PhD. PSNet primers are regu…

  8. In Conversation With… Paul G. Shekelle, MD, MPH, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd
    February 26, 2025 - In Conversation With… Paul G. Shekelle, MD, MPH, PhD October 1, 2011  Citation Text: In Conversation With… Paul G. Shekelle, MD, MPH, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49774/psn-pdf
    November 01, 2016 - www.ncbi.nlm.nih.gov/pubmed/25025944 http://www.ncbi.nlm.nih.gov/pubmed/25025944 https://www.cmqcc.org/resources-tool-kits

  10. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest | PSNet

    psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
    April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest Citation Text: Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44047/psn-pdf
    September 09, 2015 - This study examined the use of a results manager tool by primary care physicians in Partners Healthcare … Although the vast majority of providers used the tool, many did not find that it was helpful for any … specific purpose and only 64% were satisfied with the tool.

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33571/psn-pdf
    March 15, 2025 - Reporting Patient Safety Events March 15, 2025 Reporting Patient Safety Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/reporting-patient-safety-events PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in th…

  13. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected | PSNet

    psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
    September 25, 2024 - GI) endoscopy has evolved significantly in the past few decades into a critical and widely available tool

  14. In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
    October 06, 2021 - I think that the most powerful tool that we have is the way that we see things. … The patient can also look at their vital signs as a tool.

  15. In Conversation With… Matthew Weinger, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
    August 01, 2018 - perspective , Cook presented evidence that health care simulation was effective as an instructional tool … Simulation can also be a tool for administrators to increase workforce competence through better training

  16. Health Equity and Maternal Health | PSNet

    psnet.ahrq.gov/perspective/health-equity-and-maternal-health
    October 06, 2021 - I think that the most powerful tool that we have is the way that we see things. … The patient can also look at their vital signs as a tool.

  17. How Does Health Care Simulation Affect Patient Care? | PSNet

    psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
    August 01, 2018 - perspective , Cook presented evidence that health care simulation was effective as an instructional tool … Simulation can also be a tool for administrators to increase workforce competence through better training

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42474/psn-pdf
    September 19, 2015 - Based on analysis of four studies using the Global Trigger Tool, the study concludes that between 210,000 … Although the accuracy of the Global Trigger Tool for assessing preventability of harm has been questioned … psnet.ahrq.gov/issue/err-human-building-safer-health-system https://psnet.ahrq.gov/issue/ihi-global-trigger-tool-measuring-adverse-events

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39813/psn-pdf
    October 11, 2010 - This study describes a cardiopulmonary resuscitation (CPR) debriefing tool to guide postcode discussion … The authors share the practical development of the tool, its application, and lessons learned from implementation … They highlight how the tool and postcode discussions have guided identification and resolution of issues

  20. Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. | PSNet

    psnet.ahrq.gov/issue/tapping-front-line-knowledge-identifying-problems-they-occur-helps-enhance-patient-safety
    July 21, 2009 - July 21, 2009 A trigger tool to identify adverse events in the intensive care unit.  … Development and evaluation of the Institute for Healthcare Improvement global trigger tool … April 4, 2011 'Global Trigger Tool' shows that adverse events in hospitals may be ten … April 1, 2010 Adverse drug event trigger tool: a practical methodology for measuring
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