-
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.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
-
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…
-
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…
-
psnet.ahrq.gov/node/849661/psn-pdf
June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
June 28, 2023
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During
Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web…
-
psnet.ahrq.gov/issue/bundaberg-and-beyond-duty-disclose-adverse-events-patients
January 12, 2022 - Commentary
Bundaberg and beyond: duty to disclose adverse events to patients.
Citation Text:
Madden B, Cockburn T. Bundaberg and beyond: duty to disclose adverse events to patients. J Law Med. 2007;14(4):501-27.
Copy Citation
Format:
Google Scholar PubMed BibTeX EndNote X…
-
psnet.ahrq.gov/web-mm/beeline-spine
March 01, 2014 - SPOTLIGHT CASE
Beeline to Spine
Citation Text:
Smetana GW. Beeline to Spine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
-
psnet.ahrq.gov/issue/breaking-rules-understanding-non-compliance-policies-and-guidelines
September 24, 2018 - Commentary
Breaking the rules: understanding non-compliance with policies and guidelines.
Citation Text:
Carthey J, Walker S, Deelchand V, et al. Breaking the rules: understanding non-compliance with policies and guidelines. BMJ. 2011;343:d5283. doi:10.1136/bmj.d5283.
Copy Citation
…
-
psnet.ahrq.gov/issue/medicines-safety-anaesthetic-practice
February 02, 2022 - Review
Medicines safety in anaesthetic practice.
Citation Text:
Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Edu. 2019;19(5):151-157. doi:10.1016/j.bjae.2019.01.001.
Copy Citation
Format:
DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
-
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:…
-
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…
-
psnet.ahrq.gov/node/49611/psn-pdf
October 01, 2010 - Clinical Practice Guideline Number 5: Depression in Primary
Care, Volume 2: Treatment of Major Depression
-
psnet.ahrq.gov/issue/consensus-statement-effective-communication-urgent-diagnoses-and-significant-unexpected
November 16, 2022 - Organizational Policy/Guidelines
Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology.
Cit…
-
psnet.ahrq.gov/issue/medicine-wandering-mind-mind-wandering-medical-practice
August 28, 2017 - Review
Medicine for the wandering mind: mind wandering in medical practice.
Citation Text:
Smallwood J, Mrazek MD, Schooler JW. Medicine for the wandering mind: mind wandering in medical practice. Med Educ. 2011;45(11):1072-80. doi:10.1111/j.1365-2923.2011.04074.x.
Copy Citation
…
-
psnet.ahrq.gov/node/60007/psn-pdf
March 04, 2020 - ISMP Guidelines for Optimizing Safe Implementation and
Use of Smart Infusion Pumps.
March 4, 2020
Horsham, PA: Institute for Safe Medication Practices; 2020.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-implementation-and-use-smart-infusion-
pumps
Smart pumps are widely available as a medicat…
-
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…
-
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…
-
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…
-
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…
-
psnet.ahrq.gov/node/49850/psn-pdf
January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia
January 1, 2019
Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
The Case
A 72-year-old woman with a history of severe peripheral vascular dis…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
December 01, 2013 - PowerPoint Presentation
Spotlight Case
New Oral Anticoagulants
1
This presentation is based on the December 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Margaret C. Fang, MD, MPH, University of California, San Francisco
Editor, AHRQ WebM&M…