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psnet.ahrq.gov/issue/arrival-ambulance-explains-variation-mortality-time-admission-retrospective-study-admissions
January 29, 2018 - Study
Classic
Arrival by ambulance explains variation in mortality by time of admission: retrospective study of admissions to hospital following emergency department attendance in England.
Citation Text:
Anselmi L, Meacock R, Kristensen SR, et al. Arrival by amb…
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psnet.ahrq.gov/issue/effect-health-information-exchange-recognition-medication-discrepancies-interrupted-when-data
November 16, 2022 - Study
Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial.
Citation Text:
Boockvar K, Ho W, Pruskowski J, et al. Effect of health information exchange on recogni…
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psnet.ahrq.gov/issue/development-evidence-based-framework-factors-contributing-patient-safety-incidents-hospital
June 25, 2014 - Review
Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review.
Citation Text:
Lawton R, McEachan RRC, Giles SJ, et al. Development of an evidence-based framework of factors contributing to patient safety …
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psnet.ahrq.gov/issue/identifying-patient-centred-recommendations-improving-patient-safety-general-practices
April 25, 2018 - Study
Identifying patient-centred recommendations for improving patient safety in General Practices in England: a qualitative content analysis of free-text responses using the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire.
Citation Text:
Ric…
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psnet.ahrq.gov/issue/national-incidence-medication-error-surgical-patients-and-after-accreditation-council
September 23, 2020 - Study
National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform.
Citation Text:
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients Before and Afte…
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - general unit is intermittent vital signs with no way to alert clinicians to deterioration in between assessments
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psnet.ahrq.gov/web-mm/or-peeping
May 01, 2015 - OR Peeping
Citation Text:
Mackenzie CF. OR Peeping. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - Caution, Interrupted
September 1, 2004
Wears RL. Caution, Interrupted. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/caution-interrupted
The Case
A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and
neutropenia presented to the emergency department (ED) with …
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psnet.ahrq.gov/node/49472/psn-pdf
March 01, 2005 - Preventable Rash
March 1, 2005
McLean C. Preventable Rash. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/preventable-rash
The Case
A 35-year-old man with HIV was being followed in an outpatient internal medicine clinic. At a routine visit,
screening laboratories were checked. The clinic never contacted th…
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psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric
Patients at Risk of Physiologic Instability
December 23, 2020
Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at
Risk of Physiologic Instability. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm…
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psnet.ahrq.gov/node/49710/psn-pdf
May 01, 2014 - Discontinued Medications: Are They Really
Discontinued?
May 1, 2014
Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued? PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
The Case
A 69-year-old man with a history of chronic atrial f…
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psnet.ahrq.gov/node/49734/psn-pdf
May 01, 2015 - Departure From Central Line Ritual
May 1, 2015
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/departure-central-line-ritual
The Case
A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…
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psnet.ahrq.gov/node/33666/psn-pdf
October 01, 2008 - Methicillin-Resistant Staphylococcus aureus
April 1, 2008
Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
Perspective
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media …
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - 40 of K
November 1, 2003
Lesar TS. 40 of K. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/40-k
The Case
An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve
replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
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psnet.ahrq.gov/node/72693/psn-pdf
January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room
– Mixing Up the Ampules
January 29, 2021
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
The Case
A…
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psnet.ahrq.gov/node/49444/psn-pdf
May 01, 2004 - Do Me a Favor
May 1, 2004
Williamson A. Do Me a Favor. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/do-me-favor
The Case
A 26-year-old gravida 4 para 1 woman reported that her last menstrual period was 5 weeks prior, and she
had a positive home pregnancy test. With a history of one ectopic pregnancy, one…
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - Hard to Swallow
October 1, 2004
Driver J. Hard to Swallow. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/hard-swallow
The Case
An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic
attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
July 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case July 2007
Resuscitation Errors:
A Shocking Problem
Source and Credits
This presentation is based on the July 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Benjamin Abella, MD, MPhil, …
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psnet.ahrq.gov/node/49837/psn-pdf
August 01, 2018 - Abdominal Aortic Aneurysm Screening
August 1, 2018
Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
Case Objectives
Describe risk factors associated with abdominal aortic aneurysm.
Identify patient populations meeting criteria fo…
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psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable
Citation Text:
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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