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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.290_slideshow.ppt
February 01, 2013 - Spotlight Case July 2008
Spotlight Case
Delay in Treatment:
Failure to Contact Patient Leads to Significant Complications
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Source and Credits
This presentation is based on the February 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: …
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psnet.ahrq.gov/node/49418/psn-pdf
October 01, 2003 - Charcoal Lavage of the Lungs
October 1, 2003
Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
The Case
A 47-year-old man presented to an emergency department (ED) with altered mental status, and was
believed to have a probable overdose. He receiv…
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psnet.ahrq.gov/node/72616/psn-pdf
December 22, 2020 - Adverse Events in Dentistry
December 22, 2020
Kalenderian E, Walji MF, Fitall E, et al. Adverse Events in Dentistry. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/adverse-events-dentistry
Introduction
Similar to many other healthcare settings, dentistry carries with it inherent patient safety risks. D…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
May 01, 2011 - Spotlight Case July 2008
Spotlight Case
Duty to Disclose Someone Else’s Error
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Source and Credits
This presentation is based on the May 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Thomas H. Gallagher, MD University of Washington
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psnet.ahrq.gov/primer/leadership-role-improving-safety
September 15, 2024 - Leadership Role in Improving Safety
Citation Text:
Leadership Role in Improving Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - Crushing Chest Pain: A Missed Opportunity
January 1, 2004
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
Case Objectives
Appreciate the challenges of diagnosing aortic dissection
Describe a Bayesian approach to dia…
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psnet.ahrq.gov/web-mm/translating-normal-abnormal
October 02, 2019 - SPOTLIGHT CASE
Translating From Normal to Abnormal
Citation Text:
Turner AM. Translating From Normal to Abnormal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibT…
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psnet.ahrq.gov/node/49611/psn-pdf
October 01, 2010 - The Deadly Duo
October 1, 2010
Maldonado JR. The Deadly Duo. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/deadly-duo
The Case
A 29-year-old man with a history of depression and possible psychosis was found unconscious and
unresponsive at home and was brought to the emergency department. He was tachycardi…
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psnet.ahrq.gov/node/49737/psn-pdf
June 01, 2015 - Unseen Perils of Urinary Catheters
June 1, 2015
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
The Case
A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - SPOTLIGHT CASE
Crushing Chest Pain: A Missed Opportunity
Citation Text:
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google …
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psnet.ahrq.gov/web-mm/dissecting-presentation
May 05, 2021 - SPOTLIGHT CASE
Dissecting the Presentation
Citation Text:
Suat-Ooi SB. Dissecting the Presentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 …
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psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things Changed?
Helen Haskell, MA | June 1, 2014
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed?. PSNet [internet]. Ro…
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psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
December 01, 2012 - In Conversation With… Sharon K. Inouye, MD, MPH
December 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… Sharon K. Inouye, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - Only one case required cardiopulmonary resuscitation and no deaths were reported. 3 This case is an example
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - January 23, 2019
Classifying errors in preventable and potentially preventable trauma deaths
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psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - efforts are part of a larger challenge, many with “zero” as their goals, such as “Vision Zero” to reduce deaths
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
June 01, 2005 - Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer.
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psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
September 01, 2007 - A well-supported moderator should also routinely review departmental deaths, unexpected returns to the
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psnet.ahrq.gov/node/848124/psn-pdf
April 26, 2023 - had implemented a system that had a specific purpose, and it was
extremely successful at preventing deaths
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psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
June 01, 2011 - few risk analysts who see this behavior as a universal law: automobile seat belts actually do reduce deaths