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psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
May 01, 2009 - But it would have a 5- or 8-year endpoint, which allows the organization to right-size without bankruptcy … Citation
Sections
Perspective
Related Resources From the Same Author
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psnet.ahrq.gov/node/49564/psn-pdf
July 01, 2008 - Case & Commentary: Part 1
A 56-year-old man with a long history of heroin use presented to the hospital … not stated explicitly in the case
presentation, the covering provider may have been biased by the description … Year-end 2000 Emergency Department
Data from the Drug Abuse Warning Network. … Predictors and correlates of 10-
year functioning and mortality. J Stud Alcohol. 1992;53:142-153. … Overview of 5-year followup outcomes in the drug abuse
treatment outcome studies (DATOS).
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psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
September 01, 2012 - Projection results (including state-by-state demand) and description of projection models should be released … Citation
Sections
Perspective
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psnet.ahrq.gov/web-mm/compare-and-contrast
July 16, 2019 - prophylaxis Follow an algorithm for CN risk reduction and prevention Case & Commentary: Part 1 A 76-year-old … patients with acute renal failure requiring dialysis following coronary intervention was 35.7%, with a 2-year … Case & Commentary: Part 3
References
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psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - The Case A 70-year-old man with peripheral vascular disease was brought to the operating room to undergo … The Case
The Commentary
References
Figures
Related Resources From the Same Author … December 14, 2022
Description and yield of current quality and safety review in selected
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psnet.ahrq.gov/node/49549/psn-pdf
December 06, 2007 - Case & Commentary: Part 1
A 61-year-old male with a history of chronic pancreatitis and cardiomyopathy … Notification of security with a description of the missing patient and pertinent clinical information
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
December 01, 2017 - His description of one Morbidity and Mortality (M&M) conference captures the zeitgeist. … First, I made a fundamental error this early in the training year in allowing the chief resident to operate
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psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - The Case
A 48-year-old man with a long history of diabetes and end-stage renal disease (ESRD) on hemodialysis
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psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
December 23, 2020 - Case & Commentary: Part 1 A 70-year-old man with type II diabetes and chronic kidney disease was admitted … Community Even as we discuss the holy grail of an interoperable EHR, it is worth noting that the description … : Part 2
Case & Commentary: Part 3
References
Related Resources From the Same Author
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psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
August 01, 2015 - The note began at the time of Hippocrates as a narrative description of what the patient was saying. … A wise person once said: we virtually always overestimate what we can do in a year and underestimate … Silicon Valley has figured out in the last year or two that health care is the only part of the economy
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - The Case A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for … recommendation does not take into account the mother with ongoing bleeding.( 9 ) It is unclear from the case description … Take-Home Points
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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - The Case A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy cycle … The Commentary
Take-Home Points
References
Related Resources From the Same Author
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psnet.ahrq.gov/web-mm/misleading-complaint
December 01, 2009 - The Case A 54-year-old homeless man with a history of alcoholism presented to the emergency department … Sections
The Case
The Commentary
References
Related Resources From the Same Author
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psnet.ahrq.gov/node/49696/psn-pdf
December 01, 2013 - Case & Commentary—Part 1
A 39-year-old woman with a history of deep venous thrombosis (DVT) underwent
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - experienced by the Quaid twins has happened hundreds of times, and millions of medication errors occur every year … (Go to table citation in the text)
Error
Site
Year
Description and Consequences
An … 18-year-old woman, Libby Zion, daughter of a prominent reporter, dies of a medical mistake, partly due … initiatives), demonstrating the power of institution–patient collaboration
Jesica Santillan, a 17-year-old … Citation
Sections
Perspective
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - The Case
Case #1:
A 56-year-old man was admitted to the same-day surgery center for a planned … Case #2:
A 59-year-old man was treated for a suspected myocardial infarction due to erroneous cardiac … In one study, the practice of collecting rainbow draws was attributed to 275 L of blood wasted per year … The Commentary
Take-Home Points
References
Related Resources From the Same Author
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psnet.ahrq.gov/web-mm/death-pca
January 06, 2017 - The Case A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after … Five-year experience of critical incidents associated with patient-controlled analgesia in an Irish University … The Case
The Commentary
References
Tables
Related Resources From the Same Author … January 5, 2017
Harmful medication errors in children: a 5-year analysis of data from
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psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
February 26, 2025 - At the end of the year, there was a single "yes or no" primary outcome: Would patients and doctors want … medication errors, family histories that are not updated, and other documentation errors, such as incorrect description … It was a picture that a 7-year-old girl had drawn of her visit to the doctor's office. … This kind of patient feedback, even from a 7-year-old girl, is so powerful.
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psnet.ahrq.gov/web-mm/feeling-no-pain
August 30, 2023 - The Case A 33-year-old female underwent hysterectomy for refractory endometriosis. … The Case
The Commentary
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Figure
Related Resources From the Same Author
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psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
December 22, 2020 - around antibiotic and opioid stewardship in dentistry and one of the things that struck me was her description … learned when I came into the school is that the dentists are hands on from the second, third, fourth year … We do a ton of simulations from the first year, simulating how to take a medical history and how to have