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psnet.ahrq.gov/web-mm/missing-suction-tip
January 01, 2006 - SPOTLIGHT CASE
The Missing Suction Tip
Citation Text:
Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis
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psnet.ahrq.gov/web-mm/over-counter-oversight
March 21, 2009 - Over-the-Counter Oversight
Citation Text:
Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
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psnet.ahrq.gov/web-mm/recurrent-appendicitis
January 15, 2020 - "Recurrent" Appendicitis
Citation Text:
Greenberg CC. "Recurrent" Appendicitis. 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/returning-home-safely
December 22, 2018 - Returning Home Safely
Citation Text:
Toles M. Returning Home Safely. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - certification; regional medical offices; quality measurement, many of the value-based programs that we use for assessing
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - certification; regional medical offices; quality measurement, many of the value-based programs that we use for assessing
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psnet.ahrq.gov/issue/investigation-management-venous-thromboembolism-risk-patients-following-thrombolysis-acute
November 13, 2019 - Book/Report
Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke.
Citation Text:
Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke. Farnborough, UK; Healthcare…
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psnet.ahrq.gov/issue/ismp-long-term-care-advise-err
June 07, 2017 - Newsletter/Journal
ISMP Long-Term Care Advise-ERR.
Citation Text:
ISMP Long-Term Care Advise-ERR. Horsham, PA; Institute for Safe Medication Practices.
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psnet.ahrq.gov/issue/safety-anesthetic-and-perioperative-medication-practices
January 14, 2019 - Newspaper/Magazine Article
Safety of anesthetic and perioperative medication practices.
Citation Text:
Safety of anesthetic and perioperative medication practices. Meyer TA. Anesthesiology News. October 31, 2022.
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psnet.ahrq.gov/issue/disclosure-and-apology-whats-missing-advancing-programs-support-clinicians
December 07, 2016 - Book/Report
Disclosure and Apology: What's Missing? Advancing Programs that Support Clinicians.
Citation Text:
Disclosure and Apology: What's Missing? Advancing Programs that Support Clinicians. Carr S. Chestnut Hill, MA: Medically Induced Trauma Support Services; 2009.
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psnet.ahrq.gov/issue/diagnostic-safety-event-reporting
August 05, 2020 - Newspaper/Magazine Article
Diagnostic safety event reporting.
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Diagnostic safety event reporting. Carr S. ImproveDx. July 2021;8(4).
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psnet.ahrq.gov/issue/accidental-iv-infusion-heparinized-irrigation-or
September 14, 2016 - Newspaper/Magazine Article
Accidental IV infusion of heparinized irrigation in the OR.
Citation Text:
Accidental IV infusion of heparinized irrigation in the OR. ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.
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psnet.ahrq.gov/issue/studying-organisational-cultures-and-their-effects-safety
April 20, 2014 - Commentary
Studying organisational cultures and their effects on safety.
Citation Text:
Hopkins A. Studying organisational cultures and their effects on safety. Saf Sci. 2006;44(10). doi:10.1016/j.ssci.2006.05.005.
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psnet.ahrq.gov/issue/impact-professionalism-safe-surgical-care
January 23, 2017 - Commentary
The impact of professionalism on safe surgical care.
Citation Text:
Whittemore A, Surgery NES for V. The impact of professionalism on safe surgical care. J Vasc Surg. 2007;45(2):415-9.
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psnet.ahrq.gov/issue/mismatch-made-america
December 31, 2018 - Newspaper/Magazine Article
A mismatch made in America.
Citation Text:
A mismatch made in America. Butcher L. Managed Care. June 2019;28:37-39.
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psnet.ahrq.gov/issue/using-telehealth-revolutionize-speed-making-rare-disease-diagnoses
November 04, 2020 - Newspaper/Magazine Article
Using telehealth to revolutionize the speed of making rare disease diagnoses.
Citation Text:
Using telehealth to revolutionize the speed of making rare disease diagnoses. Nothaft W, Moore G, Le Cam Y. STAT. August 27, 2020.
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psnet.ahrq.gov/issue/reducing-risk-designing-safer-shame-free-health-care-environment
September 29, 2017 - Book/Report
Reducing the Risk by Designing a Safer, Shame-free Health Care Environment.
Citation Text:
Reducing the Risk by Designing a Safer, Shame-free Health Care Environment. Abrams MA, Hung LL, Kashuba AB, et al. Chicago, IL: American Medical Association; 2007.
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psnet.ahrq.gov/issue/achieving-successful-patient-safety-program-implementation-harm-reduction-strategy
February 22, 2023 - Newspaper/Magazine Article
Achieving a successful patient safety program with implementation of a harm reduction strategy.
Citation Text:
Achieving a successful patient safety program with implementation of a harm reduction strategy. Cohen JB. APSF Newsletter. 2023;38(10):93-95.
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