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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.113_slideshow.ppt
January 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case January 2006
An Ounce of Prevention
Source and Credits
This presentation is based on the Jan. 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Nils Kucher, MD; University Ho…
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psnet.ahrq.gov/node/49864/psn-pdf
June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You
in Training About Feedback and Burnout
June 1, 2019
Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About
Feedback and Burnout. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/web-mm/ounce-prevention
February 17, 2011 - SPOTLIGHT CASE
An Ounce of Prevention
Citation Text:
Kucher N. An Ounce of Prevention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7…
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psnet.ahrq.gov/node/49608/psn-pdf
August 01, 2010 - Emergent Triage Miss
August 1, 2010
Travers D. Emergent Triage Miss. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/emergent-triage-miss
The Case
A 42-year-old woman presented to a busy urban emergency department (ED) and approached the triage
nurse. The patient told the triage nurse that she had "3 days o…
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting
firm …
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psnet.ahrq.gov/node/33707/psn-pdf
February 01, 2011 - The University of Texas System Clinical Safety and
Effectiveness Course
February 1, 2011
Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and
Effectiveness Course. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv…
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psnet.ahrq.gov/node/49543/psn-pdf
September 01, 2007 - Medication Reconciliation: Whose Job Is It?
September 1, 2007
Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
Case Objectives
Appreciate the prevalence and impact of medication discrepancies at times of transition in …
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psnet.ahrq.gov/node/49606/psn-pdf
August 01, 2010 - Weighing In on Surgical Safety
August 1, 2010
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/weighing-surgical-safety
Case Objectives
Identify the comorbidites associated with obesity that place patients at higher risk for surgical
complications.
Un…
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/node/842923/psn-pdf
February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric
Patient Complicating Cardiac Surgery and Bedside Chest
Closure.
February 1, 2023
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient
Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …
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psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
August 20, 2018 - Buprenorphine and the Medically Ill Patient
Citation Text:
McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX E…
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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Mismanagement of Delirium
May 1, 2016
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/mismanagement-delirium
The Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although
fitted with a cast at a regional ho…
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psnet.ahrq.gov/node/861881/psn-pdf
January 31, 2024 - In Conversation with...Richard Ricciardi about Office-
Based Patient Safety
January 31, 2024
Ricciardi R, Lee M, Mossburg S. In Conversation with..Richard Ricciardi about Office-Based Patient Safety.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-pa…
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digital.ahrq.gov/sites/default/files/docs/HealthITandUnderservedPopulations.pdf
September 17, 2010 - National Web-Based Teleconference on Health IT and Underserved Populations: Health IT Adoption in Rural Clinical Settings
National Web-Based Teleconference on Health IT
and Underserved Populations
Health IT Adoption in Rural Clinical Settings
August 27, 2010
Moderator:
Angela Lavanderos
A…
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psnet.ahrq.gov/web-mm/breakage-picc-line
June 21, 2023 - SPOTLIGHT CASE
Breakage of a PICC Line
Citation Text:
Dimov V. Breakage of a PICC Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/manage-resident-RTI-facilitator-guide.docx
June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use
1
Management of a Resident With a Suspected Respiratory Tract Infection
Long-Term Care
Slide Title and Commentary
Slide Number and Slide
Management of a Resident With a Suspected Respiratory Tract Infection
Long-Term Care
SAY:
Welcome to this presentation, ti…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-facilitator-guide.docx
June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use
1
Improving Antibiotic Use Is a Patient Safety Issue
Long-Term Care
Slide Title and Commentary
Slide Number and Slide
Improving Antibiotic Use Is a Patient Safety Issue
Long-Term Care
SAY:
Welcome to this presentation titled “Improving Antibiotic Use Is a Patie…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use
1
Changing the System To Improve Patient Safety
Long-Term Care
Slide Title and Commentary
Slide Number and Slide
Changing the System To Improve Patient Safety
SAY:
Hello, and welcome to this presentation: “Changing the System To Improve Patient Safety.”
Sl…
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-3-readiness-form.pdf
August 01, 2005 - Is Your Organization Ready for TeamSTEPPS™?
Is Your Organization Ready for TeamSTEPPS™?
Answering these questions can help your institution understand its level of readiness to initiate
the TeamSTEPPS program. You may find it helpful to have a colleague review your responses or
to answer the questions with a large…