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psnet.ahrq.gov/node/33673/psn-pdf
September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety
September 1, 2008
Rothschild JM, Keohane C. The Role of Bar Coding and Smart Pumps in Safety. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
Perspective
Medication safety in hospitals depends on the successful execu…
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psnet.ahrq.gov/node/33881/psn-pdf
August 01, 2019 - In Conversation With… Erik Hollnagel, PhD
June 1, 2019
In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden)
as well as Visiting…
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psnet.ahrq.gov/node/49837/psn-pdf
August 01, 2018 - Abdominal Aortic Aneurysm Screening
August 1, 2018
Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
Case Objectives
Describe risk factors associated with abdominal aortic aneurysm.
Identify patient populations meeting criteria fo…
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psnet.ahrq.gov/node/49784/psn-pdf
February 01, 2017 - Safeguarding Diagnostic Testing at the Point of Care
February 1, 2017
Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
The Case
A 23-year-old woman presented to the family medicine clinic for…
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psnet.ahrq.gov/node/49725/psn-pdf
January 01, 2015 - Haste Makes Care Unsafe
January 1, 2015
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
The Case
An 80-year-old man with a history of coronary artery disease and atrial fibrillation underwent a combined
elective coronary artery bypass graft (CABG…
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psnet.ahrq.gov/node/49401/psn-pdf
May 01, 2003 - Suicidal Man With Gun
May 1, 2003
Simon RI. Suicidal Man With Gun. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/suicidal-man-gun
The Case
The patient is a 36-year-old man who came to a psychiatry clinic for outpatient evaluation of severe
depression that had persisted for nearly 2 years. On initial inter…
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psnet.ahrq.gov/node/49718/psn-pdf
January 01, 2015 - Too Much, Too Fast
September 1, 2014
Tuot D. Too Much, Too Fast. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/too-much-too-fast
The Case
A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for
fever, tachycardia, and increased respiratory secretions. H…
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psnet.ahrq.gov/node/49569/psn-pdf
September 01, 2008 - Where's the Feeding Tube?
September 1, 2008
Metheny NA, Meert KL. Where's the Feeding Tube? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wheres-feeding-tube
The Case
A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic brain injury.
Because of the injuries, he was unabl…
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psnet.ahrq.gov/node/49407/psn-pdf
July 01, 2003 - Bleeding Risk
July 1, 2003
Crowther MA. Bleeding Risk. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/bleeding-risk
The Case
A frail 78-year-old woman fell at home and fractured her left hip. Her past medical history included atrial
fibrillation, hypertension, coronary artery disease, and stroke. The surgi…
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces
Hospitalizations Among Nursing Home Residents
July 28, 2021
https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-
home-residents
Summary
The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…
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psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - Pocket Syringe Swap
May 1, 2011
Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/pocket-syringe-swap
The Case
A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for
postoperative pain management. Surgery proceeded uneventfully under…
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psnet.ahrq.gov/node/845473/psn-pdf
March 15, 2023 - Remote Patient Monitoring
March 15, 2023
Hood C, Sikka N, Van CM, et al. Remote Patient Monitoring. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/remote-patient-monitoring
Remote Patient Monitoring
The delivery of healthcare through electronic communication, or telehealth, has changed greatly since it…
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psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - A Statewide Collaborative to Support Vaginal Birth and
Reduce Unnecessary Cesarean Deliveries
July 8, 2022
https://psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-
cesarean-deliveries
Summary
Started in response to rising maternal morbidity and mortality rates in …
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psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
November 13, 2024 - Statewide Telehealth Program Enhances Access to Care, Improves Outcomes for High-Risk Pregnancies in Rural Area
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June 12, 2020
Innovation
…
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psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
October 27, 2021 - Study
Classic
Hospital board and management practices are strongly related to hospital performance on clinical quality metrics.
Citation Text:
Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performanc…
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psnet.ahrq.gov/issue/comparing-catheter-associated-urinary-tract-infection-prevention-programs-between-veterans
December 21, 2017 - Study
Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes.
Citation Text:
Mody L, Greene T, Saint S, et al. Comparing Catheter-Associated Urinary Tract Infection Prevention Programs Betwee…
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psnet.ahrq.gov/issue/do-junior-doctors-make-more-prescribing-errors-experienced-doctors-when-prescribing
February 22, 2023 - Study
Do junior doctors make more prescribing errors than experienced doctors when prescribing electronically using a computerised physician order entry system combined with a clinical decision support system? A cross-sectional study.
Citation Text:
Kalfsvel L, Wilkes S, van der Kuy H, e…
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psnet.ahrq.gov/basic-page/ucd-cmeceu-trainee-certification
November 01, 2019 - University of California, Davis, Health CME/CEU Information
WebM&M Spotlight cases on AHRQ’s PSNet offer CME/CEU and Maintenance of Certification (MOC) credit. Effective November 2019, each Spotlight Case and Commentary is certified for the AMA PRA Category 1 ™and maintenance of certification (MOC) through the Amer…
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an
Order is Not Enough
April 28, 2021
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
Disclosure of Relev…