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psnet.ahrq.gov/issue/guidelines-prevention-intravascular-catheter-related-infections
January 22, 2014 - Clinical Guideline
Guidelines for the prevention of intravascular catheter-related infections.
Citation Text:
O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. American journal of infection control. 2011;39(4 Suppl 1):…
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psnet.ahrq.gov/node/48178/psn-pdf
January 01, 2020 - ACR guidance document on MR safe practices: updates
and critical information 2019.
August 14, 2019
ACR Committee on MR Safety, Greenberg TD, Hoff MN, Gilk TB, et al. J Magn Reson Imaging.
2020;51(2):331-338.
https://psnet.ahrq.gov/issue/acr-guidance-document-mr-safe-practices-updates-and-critical-inform…
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - SPOTLIGHT CASE
Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery
Citation Text:
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery.. PSNet [internet]…
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psnet.ahrq.gov/issue/development-and-evaluation-i-pass-picu-standard-electronic-template-improve-referral
June 14, 2023 - Study
Development and evaluation of I-PASS-to-PICU: a standard electronic template to improve referral communication for inter-facility transfers to the pediatric intensive care unit.
Citation Text:
Parikh NR, Francisco LS, Balikai SC, et al. Development and evaluation of I-PASS-to-PICU:…
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psnet.ahrq.gov/issue/safety-and-communication-operating-room-safety-questionnaire-after-implementation-blood-borne
September 23, 2020 - Study
Safety and communication in the operating room: a safety questionnaire after the implementation of a blood-borne pathogen exposure checkpoint in the surgical safety checklist preprocedure time-out.
Citation Text:
Kane P, Marley R, Daney B, et al. Safety and Communication in the Ope…
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psnet.ahrq.gov/node/49737/psn-pdf
June 01, 2015 - Unseen Perils of Urinary Catheters
June 1, 2015
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
The Case
A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - Unseen Perils of Urinary Catheters
Citation Text:
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar Bib…
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx
Spotlight
Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See…
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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - Diagnostic Overshadowing Dangers
Citation Text:
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/near-miss-neonate
August 15, 2018 - Near Miss With Neonate
Citation Text:
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/issue/ashp-ppag-guidelines-providing-pediatric-pharmacy-services-hospitals-and-health-systems
April 24, 2018 - Commentary
ASHP–PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems.
Citation Text:
Eiland LS, Benner K, Gumpper KF, et al. ASHP-PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems. J Pediatr Pharmacol Ther. 2018…
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psnet.ahrq.gov/issue/2008-recommendations-pre-anesthesia-checkout-procedures
April 22, 2020 - Organizational Policy/Guidelines
2008 Recommendations for Pre-Anesthesia Checkout Procedures.
Citation Text:
2008 Recommendations for Pre-Anesthesia Checkout Procedures. ASA Committee on Equipment and Facilities. Park Ridge, IL: American Society of Anesthesiologists; 2008.
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psnet.ahrq.gov/issue/hierarchy-and-medical-error-speaking-when-witnessing-error
April 14, 2011 - Review
Emerging Classic
Hierarchy and medical error: speaking up when witnessing an error.
Citation Text:
Peadon R (R), Hurley J, Hutchinson M. Hierarchy and medical error: speaking up when witnessing an error. Safety Sci. 2020;125:104648. doi:10.1016/j.ssci.202…
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psnet.ahrq.gov/node/73899/psn-pdf
September 29, 2021 - Lost in Transitions of Care: Managing an Opioid-
Dependent Patient with Frequent Hospitalizations
September 29, 2021
Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent
Hospitalizations. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/lost-transitions-care…
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - A Painful Medication Reconciliation Mishap
January 1, 2018
CDC Clinical … Practice Guideline for Prescribing Opioids for Pain - United States, 2022.
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psnet.ahrq.gov/perspective/update-patient-engagement-safety
January 01, 2017 - Annual Perspective
Update: Patient Engagement in Safety
Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2018
View more articles from the same authors.
Citation Text:
Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. Rockvi…
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psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - An Easily Forgotten Tube
Citation Text:
Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/46831/psn-pdf
April 18, 2018 - Guideline Summary: Medication Safety.
April 18, 2018
Guideline Summary: Medication Safety. AORN J. 2018;107(4):489-494. doi:10.1002/aorn.12096.
https://psnet.ahrq.gov/issue/guideline-summary-medication-safety
Perioperative medication errors can result in patient harm as well as emotional distress among clinical
te…
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psnet.ahrq.gov/node/49420/psn-pdf
October 01, 2003 - Practice guideline for the management of infants and children 0
to 36 months of age with fever without
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psnet.ahrq.gov/node/49852/psn-pdf
February 01, 2019 - Triaging Interhospital Transfers
February 1, 2019
Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
Case Objectives
Recognize that transfer of patients between acute care hospitals is common.
Realize that the interhospital transfer…