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9981. Security Lapse | PSNet
      psnet.ahrq.gov/web-mm/security-lapse
      December 18, 2019 - Security Lapse Citation Text: Mason D. Security Lapse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

9982. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49628/psn-pdf
      June 01, 2011 - Routine Goes Awry June 1, 2011 Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/routine-goes-awry The Case A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and scheduled for a tonsillectomy and adenoidectomy. She was in ot…

9983. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60168/psn-pdf
      March 25, 2020 - Right Electrocardiogram, Wrong Patient March 25, 2020 Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient The Cases Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…

9984. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49791/psn-pdf
      April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable April 1, 2017 Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable The Case An 84-year-old wo…

9985. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33808/psn-pdf
      May 01, 2016 - Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue May 1, 2016 Jacques S, Williams E. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue Perspective Alarm fatigue occurs whe…

9986. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49463/psn-pdf
      October 14, 2004 - Moved Too Soon October 1, 2004 Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/moved-too-soon The Case A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours after arriving, while the patient was still groggy from anesthesia, a nurs…

9987. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33797/psn-pdf
      January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice January 1, 2016 Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…

9988. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49438/psn-pdf
      March 05, 2004 - OR Peeping March 1, 2004 Mackenzie CF. OR Peeping. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/or-peeping The Case A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete spontaneous abortion (miscarriage). At this community hospital, a new operating room (OR) su…

9989. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
      January 01, 2020 - Spotlight Spotlight Inpatient Stroke Management in a Patient with Type 1 Diabetes and Home Insulin Pump Source and Credits • This presentation is based on the October 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Berit B…

9990. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49456/psn-pdf
      July 12, 2004 - Glucose Roller Coaster July 1, 2004 Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/glucose-roller-coaster The Case A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was significant for dialysis-dependent, end-stage kidney d…

9991. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49659/psn-pdf
      July 01, 2012 - Sloppy and Paste July 1, 2012 Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/sloppy-and-paste The Case A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new onset chest pain. The ED physician reviewed the patient's electronic me…

9992. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49487/psn-pdf
      August 21, 2005 - Surprise Wire August 21, 2005 Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/surprise-wire The Case A 39-year-old man with a history of liver disease presented to the emergency department (ED) with gastrointestinal bleeding and altered mental status. Due to his clinic…

9993. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49827/psn-pdf
      April 01, 2018 - Walking Patient, Missing Drain April 1, 2018 Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/walking-patient-missing-drain The Case A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective …

9994. Spotlight (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.461_slideshow.ppt
      November 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…

9995. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49623/psn-pdf
      March 01, 2011 - Are We Pushing Graduate Nurses Too Fast? March 1, 2011 Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast The Case A middle-aged man was admitted to the surgical intensive care unit (SICU) following a complex surgical…

9996. CAHPS® Moving Forward: Innovations in Tools and Research Webcast (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-moving-forward-cleary-slides.pdf
      March 01, 2010 - CAHPS® Moving Forward: Innovations in Tools and Research Webcast The Value and Impact of CAHPS Paul D. Cleary, Ph.D. Yale School of Public Health www.ahrq.gov/cahps Reported Patient Experiences are Related to other Important Processes and Outcomes Among dozens of studies examined in a recent systematic revie…

9997. Section 2: Explanation of Key Concepts and Tools | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/situation/tools/index.html
      June 01, 2023 - Section 2: Explanation of Key Concepts and Tools This section contains explanations and illustrations to help you better understand and appreciate the importance of situation monitoring and TeamSTEPPS situation monitoring tools. If you teach this content or want additional insights on how the material can be mo…

9998. Accurate ADHD Diagnosis, Measure 1, Section 5, Attachment 4 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-88-measure-1-section-5-attachment-4.pdf
      January 01, 2011 - Accurate ADHD Diagnosis, Measure 1, Section 5, Attachment 4 SNAC Submission Form Measure 1: Accurate ADHD Diagnosis Section 5: Evidence Attachment 4: ADHD Guidelines Review Aspect of Care Devel…

9999. ADHD Guidelines Review (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-89-adhd-behavior-section-5-attach-4.pdf
      January 01, 2011 - ADHD Guidelines Review SNAC Submission Form ADHD Measure 2: Behavior Therapy Section 5: Evidence Attachment 4: ADHD Guidelines Review Aspect of Care Developer Guideline Recommendations …

10000. Understand-Facilitator-Guide (doc file)
       www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
       May 01, 2017 - AHRQ Safety Program for Perinatal Care Understand the Science of Safety for Perinatal Safety Understand the Science of Safety for Perinatal Safety SAY: The Understand the Science of Safety module of the AHRQ Safety Program for Perinatal Care discusses the importance of understanding system design, safe design principl…