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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
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February 9, 2021
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - apparently expressed "feelings of impending doom," but it is not clear whether cultural or communication barriers
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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - would be managing the DKA, so it would be important to drill down on the processes to
determine what barriers
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psnet.ahrq.gov/node/33730/psn-pdf
June 01, 2012 - about reporting, like everyone else, I thought about how do you get
the reports in and what are the barriers
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psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
July 01, 2012 - hospital IT needs that was profoundly (though unintentionally) biased.( 10 ) The survey found that the barriers
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
July 01, 2012 - hospital IT needs that was profoundly (though unintentionally) biased.( 10 ) The survey found that the barriers
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psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
May 01, 2013 - Although there have been some high profile successes ( 1 ), progress has been slow.( 2 ) Well-recognized barriers
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psnet.ahrq.gov/node/49820/psn-pdf
February 01, 2018 - Returning Home Safely
February 1, 2018
Toles M. Returning Home Safely. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/returning-home-safely
The Case
A 72-year-old man was admitted to the hospital after a fall at home resulting in a right humerus fracture and
shoulder dislocation, as well as other injuries …
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psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable
Citation Text:
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy C…
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psnet.ahrq.gov/node/33739/psn-pdf
October 01, 2012 - The Physical Environment: An Often Unconsidered
Patient Safety Tool
October 1, 2012
Joseph A, Malone EB. The Physical Environment: An Often Unconsidered Patient Safety Tool. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
Perspective
Now that…
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psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - Medical Devices in the "Wild"
December 1, 2014
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medical-devices-wild
The Case
A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes,
chronic pain, arthritis, and…
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in
the Operating Room
October 27, 2021
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
…
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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/33699/psn-pdf
August 01, 2010 - Operationalizing Patient Safety at Academic Medical
Centers
August 1, 2010
Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet
[internet]. 2010.
https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
Perspective
Academic medical…
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psnet.ahrq.gov/node/49739/psn-pdf
August 21, 2015 - Breathe Easy: Safe Tracheostomy Management
August 21, 2015
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
The Case
A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - so in this case suggests implicit bias, perhaps due to the patient's age, cultural or communication barriers … January 30, 2019
Barriers to self-reporting patient safety incidents by paramedics: a
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psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal-mental-health
March 29, 2023 - and Indigenous women, are at higher risk for perinatal mental health conditions but may face systemic barriers … marginalized backgrounds may be at higher risk for perinatal mental health conditions but may also face barriers
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psnet.ahrq.gov/web-mm/perils-contrast-media
March 01, 2007 - in conference calls; (iii) review of the literature; (iv) participation in focus groups to discuss barriers
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psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
November 01, 2023 - second case likely would have benefitted from securing his airway while he was awake, the cognitive barriers
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psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - In the metaphorical cheese, hazards are prevented by barriers, but holes in the
cheese represent opportunities