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psnet.ahrq.gov/node/866216/psn-pdf
July 10, 2024 - Health Plan Patient Safety Initiatives
July 10, 2024
Helwig A, Sousane Z, Mossburg S. Health Plan Patient Safety Initiatives. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
When we think of improving patient safety, we often think of strategies that can be implemen…
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psnet.ahrq.gov/node/860015/psn-pdf
September 01, 2024 - Retained Surgical Items: Definition and Epidemiology.
January 4, 2024
Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
Background
Prudent medical practice and federal and state laws r…
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psnet.ahrq.gov/node/33691/psn-pdf
December 01, 2009 - How to Identify and Manage Problem Behaviors
December 1, 2009
Rosenstein AH, O'Daniel M. How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
Perspective
The 1999 Institute of Medicine report highlighted the need for heal…
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psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
January 01, 2019 - Spotlight
Spotlight
"Do You Want Everything Done?":
Clarifying Code Status
Source and Credits
• This presentation is based on the December 2019
AHRQ WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Karl Steinberg MD, CMD, HMDC & Thaddeus
M…
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psnet.ahrq.gov/node/33649/psn-pdf
May 01, 2007 - In Conversation with...Sir Liam Donaldson, MD, MSc
May 1, 2007
In Conversation with..Sir Liam Donaldson, MD, MSc. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
Editor's Note: Sir Liam Donaldson, MD, MSc, is England's Chief Medical Officer, a post often referre…
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - Abnormal Volunteer Results
Citation Text:
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
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psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - Hold That Order
Citation Text:
Grissinger M. Hold That Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - The Wrong Channel
September 1, 2005
Gosbee JW. The Wrong Channel . PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/wrong-channel
The Case
A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial
dosing started at 50 mL/hour using a multi-channel medication pump…
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psnet.ahrq.gov/web-mm/routine-goes-awry
September 23, 2020 - Routine Goes Awry
Citation Text:
Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
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psnet.ahrq.gov/node/840175/psn-pdf
November 16, 2022 - Mechanical Prosthetic Valve Thrombosis with
Thromboembolism.
November 16, 2022
Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
The Case
A 61-year-old woman presented to …
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psnet.ahrq.gov/node/50614/psn-pdf
October 30, 2019 - In Conversation With… Vineet Chopra, MD, MSc
October 30, 2019
In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
Editor's note: Dr. Chopra is Chief of the Division of Hospital Medicine and Associate Professor of
Medicine at the…
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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
September 27, 2023 - SPOTLIGHT CASE
Missed Opportunities for Suicide Risk Assessment
Citation Text:
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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For…
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psnet.ahrq.gov/web-mm/wheres-feeding-tube
September 01, 2003 - Where's the Feeding Tube?
Citation Text:
Metheny NA, Meert KL. Where's the Feeding Tube?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room
Citation Text:
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
April 24, 2018 - The Fluidity of Diagnostic "Wet Reads"
Citation Text:
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 …
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psnet.ahrq.gov/node/49612/psn-pdf
November 01, 2010 - Treatment Challenges After Discharge
November 1, 2010
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
Case Objectives
Understand types and frequencies of adverse events occurring between patient discharge from the
hospital …
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psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
February 21, 2020 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.
Citation Text:
Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
…
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psnet.ahrq.gov/node/50769/psn-pdf
February 15, 2017 - Cultural Competence and Patient Safety
December 27, 2019
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
Background
Culture can be defined as the “personal identification, language, thoughts, co…
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psnet.ahrq.gov/node/49470/psn-pdf
December 01, 2004 - Discharge Fumbles
December 1, 2004
Forster AJ. Discharge Fumbles. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/discharge-fumbles
Case Objectives
List the types of adverse events that occur at discharge
Identify the characteristics that identify patients at high risk for errors at discharge
Understand th…
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psnet.ahrq.gov/node/49780/psn-pdf
January 01, 2017 - The Missing Abscess: Radiology Reads in the Digital Era
January 1, 2017
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
Case Objectives
Identify the most common complication of hysterectomy.
Descr…