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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Snow.pdf
January 01, 2010 - By reducing these quality gaps,
which, according to NCQA, result in more than 57,000 U.S. deaths annually … regarding patient safety
with the 1999 report To Err Is Human, stating that between 48,000 and 98,000
deaths … The National Committee for Quality Assurance (NCQA) has
suggested that 42,000 to 79,000 deaths annually
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/breast-biopsy-executive.pdf
December 01, 2009 - Number of
cases of
Number of hematomas
Number of cases of severe requiring Number of Strength of
deaths … complications; 0.09 to 0.72% of core-
needle biopsy procedures may be
affected by severe complications
Deaths … Low No deaths were reported in association
with any type of breast biopsy
procedure
Bleeding severe
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages
Citation Text:
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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…
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psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - Check the Anesthesia Machine
Citation Text:
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google Scholar BibTeX EndNote X3 XML End…
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psnet.ahrq.gov/web-mm/nonsustained-ventricular-tachycardia-after-acute-coronary-syndromes-recognizing-high-risk
September 20, 2011 - Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients
Citation Text:
Piccini JP, Newby KL, Califf R. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap
Citation Text:
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Forma…
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psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx
Spotlight
Premature Closure: Was it Just Syncope?
Source and Credits
• This presentation is based on the November 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit i…
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psnet.ahrq.gov/node/49576/psn-pdf
January 01, 2009 - To Transfer or Not to Transfer
January 1, 2009
Pines JM. To Transfer or Not to Transfer. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/transfer-or-not-transfer
Case Objectives
Explore the benefits of the continuity of hospital care.
Understand the rules and regulations behind triage and hospital choice de…
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Spotlight
Too Many Cooks in the Kitchen
Source and Credits
• This presentation is based on the August 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: Richard P. Dutton, MD, MBA
o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
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psnet.ahrq.gov/node/49711/psn-pdf
June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of
Patient Wandering
June 1, 2014
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
Case Objectives
Define patie…
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psnet.ahrq.gov/node/49646/psn-pdf
February 01, 2012 - Poorly Advanced Directives
February 1, 2012
Anderson WG. Poorly Advanced Directives. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/poorly-advanced-directives
The Case
Cared for at home by his wife and family, an 82-year-old man with multiple chronic medical conditions
described his overall health as decli…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/prostate-cancer-surveillance_executive.pdf
December 01, 2011 - could minimize both
unnecessary early curative treatments and avoidable prostate
cancer symptoms and deaths … The baseline prostate cancer mortality in 1975
was 31 deaths per 100,000 men per year and has declined … to
the current level of approximately 24 deaths per 100,000
men per year. … Data
indicated that over time the proportion of deaths due to
prostate cancer among patients diagnosed … statistics, 2011: The impact of eliminating
socioeconomic and racial disparities on premature
cancer deaths
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effectivehealthcare.ahrq.gov/sites/default/files/tech-brief-37-opiod-use-adults-comments.pdf
November 03, 2020 - Background "Opioid-related hospitalizations, emergency
department (ED) visits, and deaths are increasing … Indeed in some studies of long term opioid
use, overdose deaths seem to diminish with age. … Counties that are poor and
white have higher risk of opioid deaths because
there is higher use of opioids … at serious risk
of misuse or overdose in 2017.xi From 1999 to
2013, the rate of opioid poisoning deaths … Specifically, researchers were able to eliminate
preventable deaths and brain damage due to
opioid
-
digital.ahrq.gov/sites/default/files/docs/publication/r01hs015459-goldberg-final-report-2008.pdf
January 01, 2008 - Increasing prevalence, hospitalizations, and deaths have made heart failure a major chronic
condition … The annual
number of deaths directly from heart failure increased from 10,000 in 1968 to 42,000 in 1993
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - of maternal mortality in under-resourced settings, remains a frequent cause of preventable maternal deaths … Preventability of pregnancy-related deaths: results of a state-wide review.
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - cancer).
15
Background: Lung Cancer Screening (6)
• Lung cancer is the leading cause of cancer deaths … the concern that
overprescribing opioids has contributed to the current epidemic of
opioid overdose deaths
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psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
January 01, 2022 - 0.64% of laparoscopic cases, have a 15%
mortality rate, and account for 81% of trocar injury-related deaths … injuries occur in 0.03- 0.18% of cases, have a 2.5-5% mortality rate,
and account for 19% of the deaths
-
psnet.ahrq.gov/node/838900/psn-pdf
October 27, 2022 - 0.64% of laparoscopic
cases, have a 15% mortality rate, and account for 81% of trocar injury-related deaths … Bowel injuries
occur in 0.03- 0.18% of cases, have a 2.5-5% mortality rate, and account for 19% of the deaths
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.docx
May 01, 2017 - factors and communication breakdowns are identified as the primary root cause of maternal and perinatal deaths … Other root causes for maternal and perinatal deaths and injuries are—
Assessment,
Leadership,
Information
-
psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Hanging,
strangulation, and asphyxiation together accounted for about 60% of attempts and 24 deaths. … second
most common method was cutting with a sharp object, contributing to 23% of attempts but no deaths