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psnet.ahrq.gov/web-mm/forgotten-turn
August 01, 2018 - SPOTLIGHT CASE
The Forgotten Turn
Citation Text:
Barbour S. The Forgotten Turn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - SPOTLIGHT CASE
Don't Dismiss the Dangerous: Obstetric Hemorrhage
Citation Text:
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/privacy-or-safety
December 01, 2011 - SPOTLIGHT CASE
Privacy or Safety?
Citation Text:
Halamka JD, McGraw D. Privacy or Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - SPOTLIGHT CASE
Crushing Chest Pain: A Missed Opportunity
Citation Text:
Graber ML. Crushing Chest Pain: A Missed Opportunity. 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/node/33716/psn-pdf
September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD
September 1, 2011
In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
Editor's note: Kaveh G. Shojania, MD, is the Canada Research Chair in Patient Safety and Quality
Improvement and t…
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psnet.ahrq.gov/node/857258/psn-pdf
November 30, 2023 - Always Check the Muscle Twitch: Residual
Neuromuscular Block After Removal of a Gastric Balloon
November 30, 2023
Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of
a Gastric Balloon. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/always-check-muscle-twitch-…
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - Crushing Chest Pain: A Missed Opportunity
January 1, 2004
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
Case Objectives
Appreciate the challenges of diagnosing aortic dissection
Describe a Bayesian approach to dia…
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psnet.ahrq.gov/node/850450/psn-pdf
June 14, 2023 - The One That Got Away—Elopement of a Suicidal Patient
in the Emergency Department.
June 14, 2023
Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the
Emergency Department. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-…
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - ultrasound-guided NGT insertion. 6 Novel NGT insertion methods require the use of specialized equipment and training
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psnet.ahrq.gov/perspective/overuse-patient-safety-problem
September 01, 2014 - Perspective
Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - • Hospitals should develop physician training programs, formalize
accountability and feedback processes
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psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
November 15, 2023 - Ongoing Training: The Hospital at Home user groups provide free, publicly available materials to share
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psnet.ahrq.gov/web-mm/dependence-vs-pain
October 30, 2019 - Modifying residents' professional attitudes about substance abuse treatment and training.
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - Insufficient
Peer comparison 1 RCT Insufficient
47
Barriers and Facilitators
Barriers
• Lack of training
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - The effectiveness of care manager training in a
multidisciplinary plan-do-check-adjust cycle on prevention
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psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
November 01, 2008 - of four different hospitals across the United States and found that, depending on the physician's training
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - of four different hospitals across the United States and found that, depending on the physician's training
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psnet.ahrq.gov/node/33858/psn-pdf
May 01, 2018 - Because my brain started its training in the fax machine era with Selectric typewriters.
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psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
June 29, 2020 - Anna Legreid Dopp: My name is Anna Legreid Dopp and I am a pharmacist by training.
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psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
August 31, 2020 - This includes training around performance improvement concepts and approaches, team building, and providing