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psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
March 25, 2020 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
January 31, 2020 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - 30
Rapid Response Systems that Aim to Mitigate
Failure to Rescue in General Hospital Wards
31
Conclusions … Report
► Included a limited review & found moderate evidence for reducing opioid
dosages, but no conclusions
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psnet.ahrq.gov/node/841469/psn-pdf
December 14, 2022 - The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/primer/leadership-role-improving-safety
September 15, 2024 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/primer/never-events
June 15, 2024 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
December 15, 2024 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/primer/human-factors-engineering
December 15, 2024 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/primer/surgical-site-infections
December 15, 2024 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx
Spotlight
Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/…
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psnet.ahrq.gov/web-mm/waiting-too-long
February 01, 2013 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 2024 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd
February 26, 2025 - recommendations for patient safety practice evaluation in terms of trying to build an evidence base to reach conclusions … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/web-mm/or
August 22, 2013 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
April 24, 2018 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
May 11, 2014 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/node/854848/psn-pdf
October 31, 2023 - The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not