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psnet.ahrq.gov/node/49587/psn-pdf
May 01, 2009 - Missing Trauma
May 1, 2009
Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/missing-trauma
The Case
A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a
few minutes later by a customer, who immediately called 911. On arrival, para…
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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…
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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - Errors in Sepsis Management
May 1, 2015
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/errors-sepsis-management
Case Objectives
Define sepsis, severe sepsis, and septic shock.
Describe the severe sepsis/septic shock resuscitation bundle.
Recognize commonly encou…
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psnet.ahrq.gov/node/37417/psn-pdf
March 28, 2012 - Medication use leading to emergency department visits
for adverse drug events in older adults.
March 28, 2012
Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for
adverse drug events in older adults. Ann Intern Med. 2007;147(11):755-765.
https://psnet.ahrq.gov/issue/med…
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psnet.ahrq.gov/node/42067/psn-pdf
March 18, 2013 - Methodological variations and their effects on reported
medication administration error rates.
March 18, 2013
McLeod MC, Barber N, Franklin BD. Methodological variations and their effects on reported medication
administration error rates. BMJ Qual Saf. 2013;22(4):278-89. doi:10.1136/bmjqs-2012-001330.
https://psne…
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psnet.ahrq.gov/node/42736/psn-pdf
October 31, 2014 - Complications of daytime elective laparoscopic
cholecystectomies performed by surgeons who operated
the night before.
October 31, 2014
Vinden C, Nash DM, Rangrej J, et al. Complications of daytime elective laparoscopic cholecystectomies
performed by surgeons who operated the night before. JAMA. 2013;310(17):1837-4…
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psnet.ahrq.gov/node/47602/psn-pdf
January 27, 2019 - Association of nurse workload with missed nursing care
in the neonatal intensive care unit.
January 27, 2019
Tubbs-Cooley HL, Mara CA, Carle AC, et al. Association of Nurse Workload With Missed Nursing Care in
the Neonatal Intensive Care Unit. JAMA Pediatr. 2019;173(1):44-51.
doi:10.1001/jamapediatrics.2018.3619.
…
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psnet.ahrq.gov/node/42788/psn-pdf
January 19, 2014 - Demonstrating high reliability on accountability measures
at The Johns Hopkins Hospital.
January 19, 2014
Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the
Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531-544.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/60174/psn-pdf
March 30, 2020 - Making Healthcare Safer III Report
March 30, 2020
Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
What is the Making Healthcare Safer Report?
The Making Healthcare Safer Report represents an ef…
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psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
January 01, 2021 - vaginal packing can be
informed by a sequential active agent perspective
— This perspective involves defining
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - others articulated the notion of high reliability organizations (HROs) and identified resilience as a defining
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psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
August 02, 2015 - The second role of the program director is in defining the educational curriculum.
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psnet.ahrq.gov/node/42091/psn-pdf
December 31, 2014 - Reduction in medication errors in hospitals due to
adoption of computerized provider order entry systems.
December 31, 2014
Radley DC, Wasserman MR, Olsho LE, et al. Reduction in medication errors in hospitals due to adoption of
computerized provider order entry systems. J Am Med Info Asso. 2013;20(3):470-476. doi:…
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psnet.ahrq.gov/node/45714/psn-pdf
December 20, 2017 - US emergency department visits for outpatient adverse
drug events, 2013–2014.
December 20, 2017
Shehab N, Lovegrove MC, Geller AI, et al. US Emergency Department Visits for Outpatient Adverse Drug
Events, 2013-2014. JAMA. 2016;316(20):2115-2125. doi:10.1001/jama.2016.16201.
https://psnet.ahrq.gov/issue/us-emergenc…
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psnet.ahrq.gov/node/39045/psn-pdf
April 04, 2011 - Risks of complications by attending physicians after
performing nighttime procedures.
April 4, 2011
Rothschild JM. Risks of Complications by Attending Physicians After Performing Nighttime Procedures.
JAMA. 2009;302(14):1565-1572. doi:10.1001/jama.2009.1423.
https://psnet.ahrq.gov/issue/risks-complications-attendi…
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psnet.ahrq.gov/node/47441/psn-pdf
September 26, 2018 - Patient outcomes after the introduction of statewide ICU
nurse staffing regulations.
September 26, 2018
Law AC, Stevens JP, Hohmann S, et al. Patient Outcomes After the Introduction of Statewide ICU Nurse
Staffing Regulations. Crit Care Med. 2018;46(10):1563-1569. doi:10.1097/CCM.0000000000003286.
https://psnet.ah…
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psnet.ahrq.gov/node/47471/psn-pdf
January 27, 2019 - Association of cataract surgical outcomes with late
surgeon career stages: a population-based cohort study.
January 27, 2019
Campbell RJ, El-Defrawy SR, Gill SS, et al. Association of Cataract Surgical Outcomes With Late Surgeon
Career Stages: A Population-Based Cohort Study. JAMA Ophthalmol. 2019;137(1):58-64.
do…
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psnet.ahrq.gov/node/41866/psn-pdf
November 28, 2012 - "It's like two worlds apart": an analysis of vulnerable
patient handover practices at discharge from hospital.
November 28, 2012
Groene RO, Orrego C, Suñol R, et al. "It's like two worlds apart": an analysis of vulnerable patient handover
practices at discharge from hospital. BMJ Qual Saf. 2012;21 Suppl 1:i67-75. d…
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psnet.ahrq.gov/node/40024/psn-pdf
December 21, 2014 - Risk factors and outcomes for foreign body left during a
procedure: analysis of 413 incidents after 1,946,831
operations in children.
December 21, 2014
Camp M, Chang DC, Zhang Y, et al. Risk factors and outcomes for foreign body left during a procedure:
analysis of 413 incidents after 1 946 831 operations in child…
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psnet.ahrq.gov/node/44447/psn-pdf
September 02, 2015 - Community-, healthcare-, and hospital-acquired severe
sepsis hospitalizations in the University HealthSystem
Consortium.
September 2, 2015
Page DB, Donnelly JP, Wang HE. Community-, Healthcare-, and Hospital-Acquired Severe Sepsis
Hospitalizations in the University HealthSystem Consortium. Crit Care Med. 2015;43(9…