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461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837334/psn-pdf
     June 08, 2022 - Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab. June 8, 2022 Doorey AJ, Turi ZG, Lazzara EH, et al. Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab. Catheter …

462. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37743/psn-pdf
     June 06, 2008 - Incidence and prevention of iatrogenic urethral injuries. June 6, 2008 Kashefi C, Messer K, Barden R, et al. Incidence and prevention of iatrogenic urethral injuries. J Urol. 2008;179(6):2254-7; discussion 2257-8. doi:10.1016/j.juro.2008.01.108. https://psnet.ahrq.gov/issue/incidence-and-prevention-iatrogenic-ureth…

463. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
     January 01, 2020 - Spotlight Spotlight Discharged with IV antibiotics: When issues arise, who manages the complications? Source and Credits • This presentation is based on the February 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Monica Donnel…

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38126/psn-pdf
     December 23, 2012 - The MacArthur Fellows Program: Peter Pronovost. December 23, 2012 The John D. and Catherine T. MacArthur Foundation. https://psnet.ahrq.gov/issue/macarthur-fellows-program-peter-pronovost Through his work, Peter Pronovost, a critical care physician and professor at Johns Hopkins University School of Medicine, has …

465. An unsuspected MR projectile: a "wooden" chair with metal bracing. | PSNet
     psnet.ahrq.gov/issue/unsuspected-mr-projectile-wooden-chair-metal-bracing
     August 03, 2022 - Commentary An unsuspected MR projectile: a "wooden" chair with metal bracing. Citation Text: Ulaner GA, Colletti PM. An unsuspected MR projectile: A “wooden” chair with metal bracing. Journal of Magnetic Resonance Imaging. 2006;23(5). doi:10.1002/jmri.20573. Copy Citation Format:…

466. A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes. | PSNet
     psnet.ahrq.gov/issue/systematic-review-unintended-consequences-clinical-interventions-reduce-adverse-outcomes
     November 15, 2023 - Review A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes. Citation Text: Manojlovich M, Lee S, Lauseng D. A Systematic Review of the Unintended Consequences of Clinical Interventions to Reduce Adverse Outcomes. J Patient Saf. 2016;12(…

467. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854264/psn-pdf
     October 04, 2023 - Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023 ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3. https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures Lack of experience with distinct process…

468. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49643/psn-pdf
     December 01, 2011 - More Treatment—Better Care? December 1, 2011 Redberg R. More Treatment—Better Care? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/more-treatment-better-care The Case The patient is a 27-year-old female who presented to a 250-bed community hospital with numbness and tingling of her hands and feet. She was …

469. A piece of my mind. Mentorship malpractice. | PSNet
     psnet.ahrq.gov/issue/piece-my-mind-mentorship-malpractice
     September 16, 2020 - Commentary A piece of my mind. Mentorship malpractice. Citation Text: Chopra V, Edelson DP, Saint S. A PIECE OF MY MIND. Mentorship Malpractice. JAMA. 2016;315(14):1453-4. doi:10.1001/jama.2015.18884. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML End…

470. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. | PSNet
     psnet.ahrq.gov/issue/stop-orders-reduce-inappropriate-urinary-catheterization-hospitalized-patients-randomized
     February 23, 2022 - Study Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. Citation Text: Loeb M, Hunt D, O'Halloran K, et al. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled t…

471. Disentangling quality and safety indicator data: a longitudinal, comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals. | PSNet
     psnet.ahrq.gov/issue/disentangling-quality-and-safety-indicator-data-longitudinal-comparative-study-hand-hygiene
     March 23, 2011 - Study Disentangling quality and safety indicator data: a longitudinal, comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals. Citation Text: Mumford V, Greenfield D, Hogden A, et al. Disentangling quality and safety indicator data: a longitudi…

472. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836999/psn-pdf
     April 27, 2022 - Toolkit for Preventing CLABSI and CAUTI in ICUs. April 27, 2022 Rockville, MD: Agency for Healthcare Research and Quality; April 2022. https://psnet.ahrq.gov/issue/toolkit-preventing-clabsi-and-cauti-icus Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this cu…

473. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
     December 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case December 2006 Hidden Heparins: HIT Happens Source and Credits This presentation is based on the December 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Patrick F. Fogarty,…

474. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45540/psn-pdf
     November 01, 2016 - Performing the wrong procedure. November 1, 2016 Minnier T, Phrampus P, Waddell L. Performing the Wrong Procedure. JAMA. 2016;316(11):1207-1208. doi:10.1001/jama.2016.9134. https://psnet.ahrq.gov/issue/performing-wrong-procedure Describing an incorrect procedure incident which involved placement of a dialysis cath…

475. Toolkit for Reducing CAUTI in Hospitals. | PSNet
     psnet.ahrq.gov/issue/toolkit-reducing-cauti-hospitals
     June 21, 2016 - Toolkit Toolkit for Reducing CAUTI in Hospitals. Citation Text: Toolkit for Reducing CAUTI in Hospitals. Rockville, MD: Agency for Healthcare Research and Quality; October 2015. Copy Citation Save Save to your library Print Download PDF Share …

476. More Treatment—Better Care? | PSNet
     psnet.ahrq.gov/web-mm/more-treatment-better-care
     August 11, 2021 - More Treatment—Better Care? Citation Text: Redberg R. More Treatment—Better Care?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…

477. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
     January 01, 2021 - Spotlight Spotlight Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough Source and Credits • This presentation is based on the April 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Verna Gibbs, MD o AHRQ W…

478. Latex: a lingering and lurking safety risk. | PSNet
     psnet.ahrq.gov/issue/latex-lingering-and-lurking-safety-risk
     October 03, 2018 - Newspaper/Magazine Article Latex: a lingering and lurking safety risk. Citation Text: Latex: a lingering and lurking safety risk. Liberatore K. PA-PSRS Patient Saf Advis. 2018 March;15. Copy Citation Save Save to your library Print Download PDF S…

479. What is the NHS Safety Thermometer? | PSNet
     psnet.ahrq.gov/issue/what-nhs-safety-thermometer
     November 02, 2016 - Commentary What is the NHS Safety Thermometer? Citation Text: Power M, Stewart K, Brotherton A. What is the NHS Safety Thermometer? Clin Risk. 2012;18(5):163-169. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

480. Using behavioral insights to strengthen strategies for change. Practical applications for quality improvement in healthcare. | PSNet
     psnet.ahrq.gov/issue/using-behavioral-insights-strengthen-strategies-change-practical-applications-quality
     April 06, 2022 - Commentary Using behavioral insights to strengthen strategies for change. Practical applications for quality improvement in healthcare. Citation Text: Johansen RLR, Tulloch S. Using behavioral insights to strengthen strategies for change. Practical applications for quality improvement in…