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psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
March 24, 2021 - SPOTLIGHT CASE
Pitfalls in Diagnosing Necrotizing Fasciitis
Citation Text:
Goh T, Goh LG. Pitfalls in Diagnosing Necrotizing Fasciitis. 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/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - naloxone, secret shoppers were unable to access naloxone in nearly one-third of the pharmacies they tested … prescription drug monitoring programs (PDMPs) and prescriber education initiatives, are currently being tested … developed at Cincinnati Children’s Hospital Medical Center, called MED.Safe, has been successfully tested
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - SPOTLIGHT CASE
A Missed Bowel Perforation - the Importance of Diagnostic Reasoning
Citation Text:
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety?
Kathlyn E. Fletcher, MD, MA; Darcy A. Reed, MD, MPH | April 1, 2013
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Fletcher KE, Reed DA. Are Residency Duty Hour Rules Imp…
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psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp
October 30, 2019 - In Conversation With… Neel Shah, MD, MPP
October 30, 2019
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Citation Text:
In Conversation With… Neel Shah, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. …
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room
Citation Text:
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
February 01, 2012 - Balancing Supervision and Autonomy: An Ongoing Tension
C. Jessica Dine, MD, MA; and Jennifer S. Myers, MD | February 1, 2012
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Dine JC, Myers JS. Balancing Supervision and Autonomy:…
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psnet.ahrq.gov/perspective/long-term-care-and-response-covid-19
October 28, 2020 - When all the facilities started to be tested, we were identifying that about 25% of staff and 25% of … LP : CNAs in particular are quitting because they don’t want to be continuously tested because the process … Residents have adverse effects like nosebleeds and other problems associated with constantly being tested
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - SPOTLIGHT CASE
Intubation Mishap
Citation Text:
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - Root Cause Analysis Gone Wrong
Citation Text:
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
Citation Text:
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit
Jochen Profit, MD, MPH; Annette Scheid, MD; and Erick Ridout, MD | October 30, 2019
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Profit J, …
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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - SPOTLIGHT CASE
Unintended Consequences of CPOE
Citation Text:
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - SPOTLIGHT CASE
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
Citation Text:
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - SPOTLIGHT CASE
The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.
Citation Text:
Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.. PSNet [internet]. Rockv…
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psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and Challenges
Patrick Tighe, MD, MS; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD | March 27, 2024
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Tighe P, Mossburg S, Gal…
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psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
March 27, 2024 - In Conversation with...Patrick Tighe about Artificial Intelligence
Patrick Tighe, MD, MS
| March 27, 2024
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Tighe P. In Conversation with..Patrick Tighe about Artificial Intelligence …
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - Implementing a Fall Prevention Program
Frances Healey, RN, PhD | December 1, 2011
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Citation Text:
Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
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psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
February 26, 2025 - While the characteristics of HRO principles have inspired interventions, researchers tested a tool of … The findings showed that the tested maturity model was valid and differentiated hospitals, but that further
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psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
February 26, 2025 - While the characteristics of HRO principles have inspired interventions, researchers tested a tool of … The findings showed that the tested maturity model was valid and differentiated hospitals, but that further