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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Kohl.pdf
April 01, 2004 - increased from 5 percent to around 80 percent during their first year of life,
with a corresponding decrease
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hcup-us.ahrq.gov/reports/statbriefs/sb228-Breast-Reconstruction-For-Mastectomy.jsp
October 01, 2017 - inpatient surgery: 7.4 in 2009, 6.6 in 2010, 7.5 in 2011, 8.0 in 2012, 7.8 in 2013, 7.3 in 2014; 1% decrease
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psnet.ahrq.gov/node/866055/psn-pdf
May 29, 2024 - Reducing Preventable Patient Harm Due to Retained
Surgical Items: The RSI Bundle
May 29, 2024
https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
Summary
Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common
catego…
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psnet.ahrq.gov/node/865610/psn-pdf
April 24, 2024 - Suicide Prevention in an Emergency Department
Population: ED-SAFE
April 24, 2024
https://psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
Summary
Suicide is the 12th leading cause of death in the United States, and the 3rd leading cause of death for
people ages 15-24.1 More tha…
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psnet.ahrq.gov/node/866343/psn-pdf
December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure
with Hypertensive Emergency
December 31, 2024
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive
Emergency. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hyperte…
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psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
August 04, 2021 - Transitions in Adolescent Medicine
Citation Text:
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 …
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psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing
October 30, 2019
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
Case Objectives
List the most common errors associated with computerized…
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psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
August 01, 2005 - The Unfinished Patient Safety Agenda
Linda H. Aiken, PhD, RN | August 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Aiken LH. The Unfinished Patient Safety Agenda. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - SPOTLIGHT CASE
Diagnosing Diagnostic Mistakes
Citation Text:
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google S…
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psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
June 01, 2015 - SPOTLIGHT CASE
Empiric Steroids: the Good, the Bad, and the Ugly
Citation Text:
Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:…
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psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
July 17, 2024 - SPOTLIGHT CASE
Tough Call: Addressing Errors From Previous Providers
Citation Text:
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy…
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psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
January 01, 2014 - SPOTLIGHT CASE
Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad
Citation Text:
Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citatio…
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digital.ahrq.gov/sites/default/files/docs/2010-02-24%20Transitions%20In%20Care%20(4).pdf
January 01, 2010 - A National Web Conference on Transitions in Care
Managing Patient Care Transitions: How Health IT
Can Reduce Unnecessary Re‐Hospitalization
February 24, 2010
Presenters:
Stephen Jencks
Independent Consultant In Health Care Safety
Brian Jack
Department of Family Medicine at Boston University School of
…
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psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
August 01, 2005 - In Conversation with…Barbara A. Blakeney, MS, RN
August 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Barbara A. Blakeney, MS, RN. 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/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia
Citation Text:
Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - Do Not Disturb!
October 1, 2007
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/do-not-disturb
Case Objectives
Define professionalism.
Discuss behaviors associated with lack of professionalism.
Outline steps one should take if a significant breach of professionalism is …
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - What Happened on Telemetry?
April 1, 2019
Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/what-happened-telemetry
Case Objectives
Describe current hospital practices for continuous telemetry monitoring.
Appreciate key recommendations from the Update to Practice…
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psnet.ahrq.gov/node/33740/psn-pdf
November 01, 2012 - In Conversation With… Abraham Verghese, MD
November 1, 2012
In Conversation With… Abraham Verghese, MD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-abraham-verghese-md
Editor's note: Abraham Verghese, MD, is Professor for the Theory and Practice of Medicine at the
Stanford University S…
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart
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June 12, 2020
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx
Spotlight
Respiratory Distress after Neck Surgery: Two
Cases of Post-Operative Cervical Hematoma
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…