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psnet.ahrq.gov/web-mm/specimen-almost-lost
September 21, 2022 - Specimen Almost Lost
Citation Text:
Hehe YK. Specimen Almost Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49719/psn-pdf
September 01, 2014 - No BP During NIBP
September 1, 2014
Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/no-bp-during-nibp
The Case
An otherwise healthy 49-year-old man with atrial fibrillation was scheduled for ablation in the catheterization
laboratory under general endotracheal anes…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
July 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case July 2007
Resuscitation Errors:
A Shocking Problem
Source and Credits
This presentation is based on the July 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Benjamin Abella, MD, MPhil, …
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psnet.ahrq.gov/node/33646/psn-pdf
February 01, 2007 - In Conversation with...Joseph Britto, MD
February 1, 2007
In Conversation with..Joseph Britto, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
Editor's Note: Joseph Britto, MD, is CEO and Co-founder of Isabel Healthcare Inc. Isabel, a clinical
decision support syste…
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psnet.ahrq.gov/node/49688/psn-pdf
August 21, 2013 - Discharge Instructions in the PACU: Who Remembers?
August 21, 2013
Engel KG. Discharge Instructions in the PACU: Who Remembers? PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
The Case
A 42-year-old woman was diagnosed with a torn anterior cruciate ligament (ACL) in …
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psnet.ahrq.gov/node/72693/psn-pdf
January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room
– Mixing Up the Ampules
January 29, 2021
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
The Case
A…
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psnet.ahrq.gov/node/33782/psn-pdf
March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety
Measurement Program?
March 1, 2015
Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? PSNet [internet].
2015.
https://psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
Perspective
Much…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
January 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case January 2008
How Do Providers Recover from Errors?
Source and Credits
This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Colin P. West, MD, PhD, Mayo Clini…
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psnet.ahrq.gov/node/33823/psn-pdf
January 01, 2017 - Workplace Safety in Health Care
January 1, 2017
Simon RW, Canacari EG. Workplace Safety in Health Care. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/workplace-safety-health-care
Perspective
The patient safety movement has highlighted the risks that patients face when receiving health care. But,
impo…
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psnet.ahrq.gov/node/50842/psn-pdf
January 29, 2020 - Patient Identification Errors: A Systems Challenge
January 29, 2020
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
The Cases
The following four events involving five patients all involved…
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in
the Operating Room
October 27, 2021
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
…
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psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - Caution, Interrupted
September 1, 2004
Wears RL. Caution, Interrupted. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/caution-interrupted
The Case
A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and
neutropenia presented to the emergency department (ED) with …
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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/33832/psn-pdf
April 01, 2017 - In Conversation With… Kathleen Sutcliffe, MN, PhD
April 1, 2017
In Conversation With… Kathleen Sutcliffe, MN, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd
Editor's note: Professor Sutcliffe is a Bloomberg Distinguished Professor of Business and Medicine at
…
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psnet.ahrq.gov/node/49604/psn-pdf
June 01, 2010 - Tacit Handover, Overt Mishap
June 1, 2010
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
The Case
A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3
years earlier to treat an abdo…
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psnet.ahrq.gov/node/49674/psn-pdf
December 01, 2012 - Preventing PICC Complications: Whose Line Is It?
December 1, 2012
Moureau N. Preventing PICC Complications: Whose Line Is It? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
The Case
A 55-year-old woman with myasthenia gravis, hypertension, and hypothyroidism prese…
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psnet.ahrq.gov/node/33665/psn-pdf
March 01, 2008 - Creation of a Medical Procedure Service to Improve
Patient Safety
March 1, 2008
Smith CC, CHuang G. Creation of a Medical Procedure Service to Improve Patient Safety. PSNet [internet].
2008.
https://psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
Perspective
Introduction and …
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psnet.ahrq.gov/node/49715/psn-pdf
August 21, 2014 - Liver Biopsy: Proceed With Caution
August 21, 2014
Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
The Case
A 42-year-old woman with a history of multiple malignancies, including osteosarcoma and recurrent breast
cancer, presented t…
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6a.html
June 01, 2014 - Care Coordination Measures Atlas Update
Chapter 6. Measure Maps and Profiles (continued, 2)
Previous Page Next Page
Table of Contents
Care Coordination Measures Atlas Update
Chapter 1: Background
Chapter 2. What is Care Coordination?
Chapter 3. Care Coordination Measurement Framework
Chapter…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-section-6-b-expert-workgroup.pdf
September 18, 2014 - Section 6-B, Expert Workgroup Roster and Materials
…