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psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safetyOctober 02, 2024 - Safety I, Safety II, and the New Views of Safety Citation Text: Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX E…
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psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mbaApril 01, 2010 - JC: We have numerous areas of performance that no individual clinician or even an individual hospital
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-caseOctober 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case Citation Text: Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US …
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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-programMarch 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? Ian Scott, MBBS, MHA, MEd | March 1, 2015 Also Read a Conversation View more articles from the same authors. Citation Text: Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety …
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33756/psn-pdfOctober 01, 2013 - You can't be doing repeated, unnecessary scans and not explaining to the referring clinician and the -
psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fracturesNovember 27, 2019 - September 20, 2023 Improving emergency medicine clinician awareness of prehospital-administered
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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-careJune 01, 2003 - These alternative solutions require clinician teamwork and strict adherence to handoff communication
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33825/psn-pdfJanuary 01, 2017 - Rethinking Root Cause Analysis January 1, 2016 Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis Annual Perspective 2016 Introduction Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33835/psn-pdfJune 01, 2017 - In Conversation With… Paul Aylin, MBChB June 1, 2017 In Conversation With… Paul Aylin, MBChB. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb Editor's note: Professor Aylin is Professor of Epidemiology and Public Health at Imperial College London, where he is also Co-Direc… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49449/psn-pdfJune 01, 2004 - Lethal Vertigo June 1, 2004 Furman JM. Lethal Vertigo. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-vertigo The Case A 64-year-old woman, with no prior medical history, complained of sudden onset of severe vertigo and vomiting, without headache. Her initial blood pressure in the emergency departme… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836942/psn-pdfApril 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room April 27, 2022 Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-m… -
Spotlight Case July 2008 (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.179_slideshow.pptJuly 01, 2008 - Spotlight Case July 2008 Spotlight Case July 2008 Dependence vs. Pain Source and Credits This presentation is based on the July 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Adam J. Gordon, MD, MPH University of Pittsburgh School of M… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73643/psn-pdfAugust 01, 2022 - ECHO-Care Transitions Successfully Reduces Patient Readmissions from Skilled Nursing Facilities, Reduces Length of Stay August 25, 2021 https://psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled- nursing Summary ECHO-Care Transitions (ECHO-CT) intends to ensure cont… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49587/psn-pdfMay 01, 2009 - Missing Trauma May 1, 2009 Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/missing-trauma The Case A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a few minutes later by a customer, who immediately called 911. On arrival, para… -
Spotlight Case [MONTH] 2003 (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.60_slideshow.pptMay 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case May 2004 Too Tight Control: The Risks of Intensive Insulin Therapy Source and Credits This presentation is based on the May 2004 AHRQ WebM&M Spotlight Case in Medicine CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Comm… -
Spotlight (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.461_slideshow.pptNovember 01, 2018 - Spotlight Spotlight Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees * Source and Credits This presentation is based on the November 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Olle ten C… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49742/psn-pdfSeptember 01, 2015 - A Fumbled Handoff to Inpatient Rehab September 1, 2015 Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab The Case An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49748/psn-pdfDecember 01, 2015 - Managing Ascites: Hazards of Fluid Removal December 1, 2015 Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal The Case A 50-year-old man with longstanding alcoholic cirrhosis presented to the emergency department (ED) w… -
Spotlight Case [MONTH] 2003 (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.pptNovember 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case November 2006 Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Source and Credits This presentation is based on the November 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is… -
PowerPoint Presentation (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.pptOctober 01, 2015 - PowerPoint Presentation Spotlight The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy 1 This presentation is based on the October 2015 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/ CME credit is available Commentary by: Jacob Reider,…
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