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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx
Spotlight
Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/…
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psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
August 10, 2025 - Breadcrumb
Home
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Implementation of Patient Safety Projects
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Created By: Lorri Zipperer, Cybraria…
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psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
January 13, 2010 - SPOTLIGHT CASE
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
Citation Text:
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - SPOTLIGHT CASE
The Perils of Cross Coverage
Citation Text:
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - SPOTLIGHT CASE
The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy
Citation Text:
Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/node/34137/psn-pdf
February 06, 2018 - Anesthesia Patient Safety Foundation.
February 6, 2018
P.O. Box 6668, Rochester, MN 55903.
https://psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation
The Anesthesia Patient Safety Foundation's (APSF) mission is to ensure that no patient is harmed by the
effects of anesthesia. To achieve that mission, APSF s…
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psnet.ahrq.gov/node/37169/psn-pdf
October 06, 2011 - The safety journal: lessons learned with an error
reporting tool to stimulate systems thinking.
October 6, 2011
Singh R, Naughton B, Singh A, et al. The Safety Journal. J Patient Saf. 2007;3(3):135-141.
doi:10.1097/0b013e31814258db.
https://psnet.ahrq.gov/issue/safety-journal-lessons-learned-error-reporting-tool-s…
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psnet.ahrq.gov/node/40134/psn-pdf
February 17, 2011 - Sleep deprivation, elective surgical procedures, and
informed consent.
February 17, 2011
Nurok M, Czeisler CA, Lehmann LS. Sleep deprivation, elective surgical procedures, and informed
consent. N Engl J Med. 2010;363(27):2577-9. doi:10.1056/NEJMp1007901.
https://psnet.ahrq.gov/issue/sleep-deprivation-elective-surg…
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psnet.ahrq.gov/node/42145/psn-pdf
March 27, 2013 - Trends in adverse events over time: why are we not
improving?
March 27, 2013
Shojania KG, Thomas EJ. Trends in adverse events over time: why are we not improving? BMJ Qual Saf.
2013;22(4):273-7. doi:10.1136/bmjqs-2013-001935.
https://psnet.ahrq.gov/issue/trends-adverse-events-over-time-why-are-we-not-improving
Th…
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psnet.ahrq.gov/node/40858/psn-pdf
December 29, 2014 - Patients' and healthcare workers' perceptions of a patient
safety advisory.
December 29, 2014
Schwappach DLB, Frank O, Koppenberg J, et al. Patients' and healthcare workers' perceptions of a patient
safety advisory. Int J Qual Health Care. 2011;23(6):713-20. doi:10.1093/intqhc/mzr062.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/40464/psn-pdf
June 10, 2018 - Multiple latent failures align to allow a serious drug
interaction to harm a patient.
June 10, 2018
ISMP Medication Safety Alert! Acute care edition. May 5, 2011;16:1-3.
https://psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient
Detailing a case in which latent failures…
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psnet.ahrq.gov/node/37108/psn-pdf
October 04, 2011 - Electronic prescribing systems in pediatrics: the rationale
and functionality requirements.
October 4, 2011
Technology AA of PC on CI, Gerstle RS. Electronic prescribing systems in pediatrics: the rationale and
functionality requirements. Pediatrics. 2007;119(6):1229-31.
https://psnet.ahrq.gov/issue/electronic-pre…
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psnet.ahrq.gov/node/836877/psn-pdf
May 16, 2022 - on patient safety—any opportunity we get to just reiterate that those are out there to be used and
encourage
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - How much of this is fear that, in fact, it will encourage lawsuits?
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psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
December 01, 2010 - How much of this is fear that, in fact, it will encourage lawsuits?
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psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
March 01, 2008 - So we do try to encourage the learning to take place under appropriate guidance and supervision before
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psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
October 24, 2021 - And then similarly, CPESN [Community Pharmacy Enhanced Services Network] is working to encourage community
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - SPOTLIGHT CASE
A Lot of Pain (Medications)
Citation Text:
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - SPOTLIGHT CASE
Mobility Lost in the ICU
Citation Text:
Smith J. Mobility Lost in the ICU. 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 EndNot…
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psnet.ahrq.gov/node/846975/psn-pdf
March 28, 2023 - In Conversation with... Christie Allen about Maternal
Safety and Perinatal Mental Health
March 28, 2023
In Conversation with.. Christie Allen about Maternal Safety and Perinatal Mental Health. PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal…