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psnet.ahrq.gov/node/33858/psn-pdf
May 01, 2018 - the history of technological
disruption and innovation in other industries says that people don't understand
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - That’s such an important message that radiologists and the general public need to understand.
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - epidemiologists, focused on coming up with standardized definitions using benchmark data, trying to understand
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psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
February 01, 2012 - But, I think it was important to understand that this training program watching him for 4 years had made
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psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
May 01, 2008 - ten different alarms going off at the same time without it being integrated in a way that they can understand
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - Ataxia is absent in the patient who cannot understand or is paralyzed.
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - Clear and effective discharge instructions are critical to ensure patients understand directions for
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psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
May 01, 2018 - ten different alarms going off at the same time without it being integrated in a way that they can understand
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psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
February 01, 2012 - But, I think it was important to understand that this training program watching him for 4 years had made
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psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
March 27, 2024 - but the history of technological disruption and innovation in other industries says that people don't understand
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care
Source and Credits
• This presentation is based on the 2020 AHRQ WebM&M Spotlight
Case
○ See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD
○ Editor…
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psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse
Outcomes
July 8, 2022
Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
The Cases
Case 1: A 64-year-old man came in for a routine bron…
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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…
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psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD
August 1, 2012
In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
Editor's note: The topic of patient safety in long-term care facilities has not received the attent…
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psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
November 16, 2022 - Annual Perspective
Annual Perspective: Psychological Safety of Healthcare Staff
March 31, 2022
View more articles from the same authors.
Citation Text:
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. P…
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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…
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - SPOTLIGHT CASE
Failure to Report
Citation Text:
Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
January 13, 2021 - Delayed Sepsis Management Due to Ambiguous Allergy
Citation Text:
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Schol…
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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors
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March 3, 2021
Innovation…
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - Mismanagement of Delirium
Citation Text:
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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