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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - SPOTLIGHT CASE
Difficult Encounters: A CMO and CNO Respond
Citation Text:
Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
October 30, 2024 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department
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July 10, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Rapid Response Systems
Curated Library
Primers
Rapid Response Systems
UC Davis PSNet Editorial Team | September, 15 2024
Rapid response teams represent an intuitively simple concept: when a patient demonstrates signs of
imminent clinical de…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.197_slideshow.ppt
April 01, 2009 - Spotlight Case July 2008
Spotlight Case
Breakage of a PICC Line
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Source and Credits
This presentation is based on the April 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Vesselin Dimov, MD
Creighton University
Editor, AHRQ WebM&M: …
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psnet.ahrq.gov/sites/default/files/2021-09/Battle%20Buddy%20Pocket%20Card%20-%20final%20(1).pdf
January 01, 2021 - COVID 19 Battle Buddy Support Program
Background: COVID-19 is a pandemic that threatens not only our patients but
ourselves and our sense of safety and control. Like soldiers on a battlefield, our
front line staff are coping with ongoing uncertainty about the scope of the
threat, concerns about adequate PPE, …
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?
Citation Text:
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
C…
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
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psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument
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January …
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psnet.ahrq.gov/node/49675/psn-pdf
February 01, 2013 - Delay in Treatment: Failure to Contact Patient Leads to
Significant Complications
February 1, 2013
Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet
[internet]. 2013.
https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complicat…
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psnet.ahrq.gov/node/33742/psn-pdf
December 01, 2012 - In Conversation With… Sharon K. Inouye, MD, MPH
December 1, 2012
In Conversation With… Sharon K. Inouye, MD, MPH. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
Editor's note: Sharon K. Inouye, MD, MPH, one of the world's leaders in geriatrics research and
innovatio…
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psnet.ahrq.gov/node/33732/psn-pdf
July 01, 2012 - think they need them in 2012 so they can learn to use them, grow with them, and
become part of the developing
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psnet.ahrq.gov/node/48187/psn-pdf
August 21, 2019 - How medical error shapes physicians' perceptions of
learning: an exploratory study.
August 21, 2019
Shepherd L, LaDonna KA, Cristancho SM, et al. How Medical Error Shapes Physicians' Perceptions of
Learning: An Exploratory Study. Acad Med. 2019;94(8):1157-1163. doi:10.1097/ACM.0000000000002752.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/44081/psn-pdf
April 22, 2015 - Accuracy of harm scores entered into an event reporting
system.
April 22, 2015
Abbasi T, Adornetto-Garcia D, Johnston PA, et al. Accuracy of harm scores entered into an event reporting
system. J Nurs Adm. 2015;45(4):218-225. doi:10.1097/NNA.0000000000000188.
https://psnet.ahrq.gov/issue/accuracy-harm-scores-entere…
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psnet.ahrq.gov/node/37729/psn-pdf
June 12, 2008 - Introduction of medical emergency teams in Australia and
New Zealand: a multi-centre study.
June 12, 2008
Jones D, George C, Hart GK, et al. Introduction of medical emergency teams in Australia and New
Zealand: a multi-centre study. Crit Care. 2008;12(2):R46. doi:10.1186/cc6857.
https://psnet.ahrq.gov/issue/introd…
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psnet.ahrq.gov/node/41101/psn-pdf
October 16, 2012 - System-related interventions to reduce diagnostic errors:
a narrative review.
October 16, 2012
Singh H, Graber ML, Kissam SM, et al. System-related interventions to reduce diagnostic errors: a
narrative review. BMJ Qual Saf. 2012;21(2):160-170. doi:10.1136/bmjqs-2011-000150.
https://psnet.ahrq.gov/issue/system-rel…
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psnet.ahrq.gov/node/36909/psn-pdf
January 05, 2017 - Medical team training: applying crew resource
management in the Veterans Health Administration.
January 5, 2017
Dunn EJ, Mills PD, Neily J, et al. Medical team training: applying crew resource management in the
Veterans Health Administration. Jt Comm J Qual Patient Saf. 2007;33(6):317-325.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/41702/psn-pdf
November 07, 2018 - AHRQ patient safety project reduces bloodstream
infections by 40 percent.
November 7, 2018
Schmidt B. Patient Saf Qual Hcare. September 12, 2012.
https://psnet.ahrq.gov/issue/ahrq-patient-safety-project-reduces-bloodstream-infections-40-percent
The near elimination of central line–associated bloodstream infections…
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psnet.ahrq.gov/node/73397/psn-pdf
June 16, 2021 - Safe opioid prescribing: a prognostic machine learning
approach to predicting 30-day risk after an opioid
dispensation in Alberta, Canada.
June 16, 2021
Sharma V, Kulkarni V, Eurich DT, et al. Safe opioid prescribing: a prognostic machine learning approach to
predicting 30-day risk after an opioid dispensation in …
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psnet.ahrq.gov/node/45598/psn-pdf
November 23, 2016 - AHRQ Nursing Home Survey on Patient Safety Culture:
2016 User Comparative Database Report.
November 23, 2016
Famolaro T, Yount ND, Greene, K, Hare R, Thorton S, Sorra J. Rockville, MD: Agency for Healthcare
Research and Quality; October 2016. AHRQ Publication No. 17-0004-EF.
https://psnet.ahrq.gov/issue/ahrq-nursi…
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psnet.ahrq.gov/node/45083/psn-pdf
July 18, 2016 - Toward a safer health care system: the critical need to
improve measurement.
July 18, 2016
Jha AK, Pronovost P. Toward a Safer Health Care System: The Critical Need to Improve Measurement.
JAMA. 2016;315(17):1831-2. doi:10.1001/jama.2016.3448.
https://psnet.ahrq.gov/issue/toward-safer-health-care-system-critical-n…