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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.17_slideshow.ppt
June 01, 2003 - PowerPoint Presentation
Spotlight Case June 2003
Missed Appendicitis
webmm.ahrq.gov
Source and Credits
This presentation is based on June 2003
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: James Adams, MD, Fei…
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psnet.ahrq.gov/node/33636/psn-pdf
July 01, 2006 - Key Issues in Developing a Successful Hospital Safety
Program
July 1, 2006
Whittington JC. Key Issues in Developing a Successful Hospital Safety Program. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
Perspective
What are the key success factors…
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psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
August 21, 2007 - SPOTLIGHT CASE
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
Citation Text:
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Huma…
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - Crossed Coverage
Citation Text:
Kayser SR. Crossed Coverage. 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 Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - record and requires that they be completed within 30 days of discharge.( 8 ) This is far too permissive, considering … mandated that all hospitals publicly report care transition measure scores, and two other states are considering
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - mandated that all hospitals publicly report care transition measure scores, and two other states are considering … record and requires that they be completed within 30 days of discharge.( 8 ) This is far too permissive, considering
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psnet.ahrq.gov/node/44021/psn-pdf
March 25, 2015 - Quick Safety.
March 25, 2015
Oakbrook Terrace, IL: The Joint Commission.
https://psnet.ahrq.gov/issue/quick-safety
This newsletter provides brief introductions to specific patient safety concerns or incidents and includes
recommendations to consider for improvement.
https://psnet.ahrq.gov/issue/quick-safety
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psnet.ahrq.gov/node/35065/psn-pdf
October 05, 2005 - Why the need to reduce medical errors is not obvious.
October 5, 2005
Buetow S.
https://psnet.ahrq.gov/issue/why-need-reduce-medical-errors-not-obvious
The author considers whether medical errors are always problematic and asserts a distinction between
desirable and undesirable errors.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/35370/psn-pdf
November 28, 2016 - Going to the hospital? Don't forget to pack a nurse.
November 28, 2016
Tugend A.
https://psnet.ahrq.gov/issue/going-hospital-dont-forget-pack-nurse
This article discusses concerns about nurse shortages and why a patient or family might consider retaining
a private-duty nurse for a hospital stay.
https://psnet.ahr…
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psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue
Citation Text:
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Cit…
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psnet.ahrq.gov/node/49673/psn-pdf
December 01, 2012 - A Real Heartache
December 1, 2012
Polevoi SK. A Real Heartache. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/real-heartache
The Case
A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The
pain began at rest, and it radiated to his back and left axilla. He had…
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psnet.ahrq.gov/node/36673/psn-pdf
January 18, 2011 - Patient safety: honoring advanced directives.
January 18, 2011
Tice MA. Patient safety: honoring advanced directives. Home Healthc Nurse. 2007;25(2):79-81.
https://psnet.ahrq.gov/issue/patient-safety-honoring-advanced-directives
The author discusses why failure to follow an advance directive should be considered a …
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psnet.ahrq.gov/node/36125/psn-pdf
April 03, 2012 - Safe handover in psychiatry: is it time to set standards?
April 3, 2012
Gulati G.
https://psnet.ahrq.gov/issue/safe-handover-psychiatry-it-time-set-standards
The investigators asked National Health Service consultants and house officers what they would
consider an ideal handoff in psychiatric care. They found that…
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psnet.ahrq.gov/node/39849/psn-pdf
September 15, 2010 - The need for risk profiling in patient safety.
September 15, 2010
Donaldson LJ, Noble DJ. The need for risk profiling in patient safety. J Patient Saf. 2010;6(3):125-7.
doi:10.1097/PTS.0b013e3181ed73a3.
https://psnet.ahrq.gov/issue/need-risk-profiling-patient-safety
This commentary describes the need for health ca…
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psnet.ahrq.gov/node/35194/psn-pdf
December 09, 2008 - Drug errors, qualitative research and some reflections on
ethics.
December 9, 2008
Armitage G. Drug errors, qualitative research and some reflections on ethics. J Clin Nurs. 2005;14(7):869-
75.
https://psnet.ahrq.gov/issue/drug-errors-qualitative-research-and-some-reflections-ethics
In this position paper, the au…
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psnet.ahrq.gov/node/39815/psn-pdf
March 18, 2011 - Introducing new technology safely.
March 18, 2011
Mytton OT, Velazquez A, Banken R, et al. Introducing new technology safely. Qual Saf Health Care.
2010;19 Suppl 2:i9-14. doi:10.1136/qshc.2009.038554.
https://psnet.ahrq.gov/issue/introducing-new-technology-safely
This report describes the distinction between techn…
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psnet.ahrq.gov/issue/patient-safety-and-staff-competence-managing-challenging-behavior-based-feedback-former
October 15, 2016 - Study
Patient safety and staff competence in managing challenging behavior based on feedback from former psychiatric patients.
Citation Text:
Tölli S, Kontio R, Partanen P, et al. Patient safety and staff competence in managing challenging behavior based on feedback from former psychiatr…
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psnet.ahrq.gov/node/49409/psn-pdf
July 01, 2003 - Feeling No Pain
July 1, 2003
Bogner MS. Feeling No Pain. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/feeling-no-pain
The Case
A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the
patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…
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psnet.ahrq.gov/node/49619/psn-pdf
February 01, 2011 - Paradoxical Pulse
February 1, 2011
Roy CL. Paradoxical Pulse. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/paradoxical-pulse
The Case
An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful
pacemaker placement as an outpatient. The patient was restarted on …
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psnet.ahrq.gov/node/38477/psn-pdf
October 03, 2017 - Serious Adverse Events Reports.
October 3, 2017
The Quality Improvement Committee. Wellington, New Zealand; 2006-2013.
https://psnet.ahrq.gov/issue/serious-adverse-events-reports
Considered a starting point for a national reporting initiative, this series of annual reports provides statistics
on serious and sentin…