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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Inpatient diagnostic assessments: 1. accuracy of
structured vs. unstructured interviews.
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psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
December 08, 2021 - Race/ethnicity, language, and patients' assessments of care in Medicaid managed care.
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - categories for the breast imager to properly use... there is considerable interobserver variability in the assessments
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - end of the spectrum are multifactorial interventions involving comprehensive structured individual assessments
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - A physician and respiratory therapist performed intake assessments, but their documentation only addressed
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - Pharmacist medication assessments in a surgical preadmission clinic.
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psnet.ahrq.gov/issue/patient-safety-tools-improving-safety-point-care
December 24, 2008 - Grant Recipient
Patient Safety Tools: Improving Safety at the Point of Care.
Citation Text:
Patient Safety Tools: Improving Safety at the Point of Care. Agency for Healthcare Research and Quality.
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psnet.ahrq.gov/node/42331/psn-pdf
June 05, 2013 - Using the ABCs of situational awareness for patient
safety.
June 5, 2013
Cohen NL. Using the ABCs of situational awareness for patient safety. Nursing (Brux). 2013;43(4):64-5.
doi:10.1097/01.NURSE.0000428332.23978.82.
https://psnet.ahrq.gov/issue/using-abcs-situational-awareness-patient-safety
This commentary exa…
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psnet.ahrq.gov/node/48031/psn-pdf
May 22, 2019 - In harm's way.
May 22, 2019
Donaldson LJ, Lemer C, Titcombe J. In harm's way. BMJ. 2019;365:l2037. doi:10.1136/bmj.l2037.
https://psnet.ahrq.gov/issue/harms-way
This commentary recommends that health care structure the work environment to address conditions that
allow for failure. The authors discuss how increased…
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - Unlike risk assessments used to estimate the likelihood of other clinical entities (e.g., pulmonary embolism
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psnet.ahrq.gov/node/41833/psn-pdf
November 14, 2012 - Risks related to patient bed safety.
November 14, 2012
Sharkey JE, Van Leuven K, Radovich P. Risks related to patient bed safety. J Nurs Care Qual.
2012;27(4):346-51. doi:10.1097/NCQ.0b013e318264744b.
https://psnet.ahrq.gov/issue/risks-related-patient-bed-safety
Reviewing the three major contributing factors to me…
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psnet.ahrq.gov/node/44354/psn-pdf
August 05, 2015 - Evaluation for occult fractures in injured children.
August 5, 2015
Wood JN, French B, Song L, et al. Evaluation for Occult Fractures in Injured Children. Pediatrics.
2015;136(2):232-40. doi:10.1542/peds.2014-3977.
https://psnet.ahrq.gov/issue/evaluation-occult-fractures-injured-children
This study assessed an err…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
December 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case December 2007
Elopement
Source and Credits
This presentation is based on the December 2007 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Debra Gerardi, RN, MPH, JD
Creighton University School of Law
Ed…
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psnet.ahrq.gov/node/49404/psn-pdf
June 01, 2003 - Not a Miscarriage
June 1, 2003
Learman LA. Not a Miscarriage. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/not-miscarriage
The Case
A 32-year-old woman, gravida 3, para 1, with a history of Type 2 diabetes mellitus on metformin, presented
at 7 and 2/7 weeks by last menstrual period (LMP). The patient rep…
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psnet.ahrq.gov/node/49854/psn-pdf
February 01, 2019 - Diagnostic Failure: The Growing Deficit
February 1, 2019
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
The Case
A 65-year-old woman with a history of diabetes and hypertension was admitted to a hospital's telem…
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psnet.ahrq.gov/node/49661/psn-pdf
August 01, 2012 - Residual Anesthesia: Tepid Burn
August 1, 2012
Kurrek MM, Twersky RS. Residual Anesthesia: Tepid Burn. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
The Case
A 42-year-old Filipino man presented to an outpatient surgery center for scheduled repair of an anal fistula.
The pat…
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psnet.ahrq.gov/node/47966/psn-pdf
May 29, 2019 - Patient Safety Essentials Toolkit.
May 29, 2019
Boston, MA: Institute for Healthcare Improvement; 2019.
https://psnet.ahrq.gov/issue/patient-safety-essentials-toolkit
This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis,
and communication as well as templates to …
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psnet.ahrq.gov/node/47280/psn-pdf
October 15, 2018 - Master of Healthcare Quality and Safety.
October 15, 2018
Harvard Medical School.
https://psnet.ahrq.gov/issue/master-healthcare-quality-and-safety
This one-year degree program will train clinicians and health care executives to lead safety and quality
improvement initiatives. Participants will learn how to develo…
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psnet.ahrq.gov/node/49549/psn-pdf
December 06, 2007 - Elopement
December 1, 2007
Gerardi D. Elopement. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/elopement
Case Objectives
Define elopement and differentiate it from wandering and leaving against medical advice.
Identify leading contributors to elopement events.
Describe strategies for preventing elopement…
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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx
Spotlight
Challenging Case of Multiple Suicide Attempts in a
Complex Patient with Psychiatric Comorbidities
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…