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psnet.ahrq.gov/node/865570/psn-pdf
April 10, 2024 - Risk Mitigation Using the Anesthesia Risk Alert Program:
Applying a Proactive Approach With Data Review &
Collaborating With a Second Practitioner
April 10, 2024
https://psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-
approach-data
Summary
North American Partners…
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psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
April 12, 2023 - By allowing for real time evaluation of patients by expert consultants in advance of transfer, telemedicine
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psnet.ahrq.gov/issue/my-whole-room-went-chaos-because-thing-corner-unintended-consequences-central-fetal
February 15, 2023 - Study
"My whole room went into chaos because of that thing in the corner": unintended consequences of a central fetal monitoring system.
Citation Text:
Small K, Sidebotham M, Gamble J, et al. “My whole room went into chaos because of that thing in the corner”: unintended consequences of …
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psnet.ahrq.gov/issue/involving-patients-and-carers-patient-safety-primary-care-qualitative-study-co-designed
February 22, 2023 - Study
Involving patients and carers in patient safety in primary care: a qualitative study of a co-designed patient safety guide.
Citation Text:
Morris RL, Giles SJ, Campbell S. Involving patients and carers in patient safety in primary care: a qualitative study of a co‐designed patient …
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psnet.ahrq.gov/issue/safety-and-acceptability-using-telehealth-follow-patients-following-cancer-surgery-systematic
December 23, 2020 - Review
The safety and acceptability of using telehealth for follow-up of patients following cancer surgery: a systematic review.
Citation Text:
Xiao K, Yeung JC, Bolger JC. The safety and acceptability of using telehealth for follow-up of patients following cancer surgery: a systematic r…
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psnet.ahrq.gov/issue/how-satisfied-are-patients-and-surgeons-telemedicine-orthopaedic-care-during-covid-19
July 15, 2020 - Review
Classic
How satisfied are patients and surgeons with telemedicine in orthopaedic care during the COVID-19 pandemic? A systematic review and meta-analysis.
Citation Text:
Chaudhry H, Nadeem S, Mundi R. How Satisfied Are Patients and Surgeons with Telemedic…
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psnet.ahrq.gov/issue/why-safety-intrapartum-electronic-fetal-monitoring-so-hard-qualitative-study-combining-human
October 21, 2020 - Study
Why is safety in intrapartum electronic fetal monitoring so hard? A qualitative study combining human factors/ergonomics and social science analysis.
Citation Text:
Lamé G, Liberati EG, Canham A, et al. Why is safety in intrapartum electronic fetal monitoring so hard? A qualitative…
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psnet.ahrq.gov/node/49473/psn-pdf
March 01, 2005 - "(2)
Second, the role played by the cardiology consultant illustrates another missed intervention opportunity
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psnet.ahrq.gov/issue/missed-diagnosis-cancer-primary-care-insights-malpractice-claims-data
March 15, 2017 - Study
Missed diagnosis of cancer in primary care: insights from malpractice claims data.
Citation Text:
Aaronson E, Quinn GR, Wong CI, et al. Missed diagnosis of cancer in primary care: Insights from malpractice claims data. J Healthc Risk Manag. 2019;39(2):19-29. doi:10.1002/jhrm.21385.…
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - The trauma surgery team and orthopedic consultant were correct to adopt a deliberate and conservative … Emergency general surgery and trauma: Outcomes from the first consultant-led service in Singapore.
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psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
Discharged with IV antibiotics:
When issues arise, who manages
the complications?
Source and Credits
• This presentation is based on the February 2020 AHRQ
WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Monica Donnel…
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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - First, the preoperative consultant sowed the seeds of this adverse event by obtaining the wrong preadmission … The consultant also failed to verify the medication history; he did not contact the patient's PCP, neurologist
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psnet.ahrq.gov/issue/medication-errors-among-acutely-ill-and-injured-children-treated-rural-emergency-departments
December 13, 2013 - Study
Medication errors among acutely ill and injured children treated in rural emergency departments.
Citation Text:
Marcin JP, Dharmar M, Cho M, et al. Medication errors among acutely ill and injured children treated in rural emergency departments. Ann Emerg Med. 2007;50(4):361-7, 36…
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psnet.ahrq.gov/issue/evaluation-problem-specific-sbar-tool-improve-after-hours-nurse-physician-phone-communication
December 30, 2014 - Study
Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial.
Citation Text:
Joffe E, Turley JP, Hwang KO, et al. Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a ra…
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psnet.ahrq.gov/node/850450/psn-pdf
June 14, 2023 - The One That Got Away—Elopement of a Suicidal Patient
in the Emergency Department.
June 14, 2023
Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the
Emergency Department. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-…
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psnet.ahrq.gov/issue/effects-sleep-inertia-cognition
April 21, 2021 - 21, 2017
View More
Related Resources
Prospective evaluation of consultant
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psnet.ahrq.gov/node/49805/psn-pdf
September 01, 2017 - The Forgotten Radiographic Read
September 1, 2017
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read
The Case
A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for
management of inferior…
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psnet.ahrq.gov/issue/variations-gps-decisions-investigate-suspected-lung-cancer-factorial-experiment-using
August 03, 2022 - Study
Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes.
Citation Text:
Sheringham J, Sequeira R, Myles J, et al. Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia …
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psnet.ahrq.gov/node/35035/psn-pdf
March 17, 2011 - Scottish Audit of Surgical Mortality.
March 17, 2011
Scottish Audit of Surgical Mortality and Royal College of Physicians and Surgeons of Glasgow.
https://psnet.ahrq.gov/issue/scottish-audit-surgical-mortality
The Scottish Audit of Surgical Mortality (SASM) facilitates the peer review of all surgical deaths in Scot…
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psnet.ahrq.gov/issue/medical-error
August 07, 2018 - Consultant surgeon's contemporary experience of adverse surgical events.