-
psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - provide feedback to institutions and vendors so all can learn how to improve CPOE design and usability; Ensuring
-
psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - Checklists have a long and successful history in a range of other industries ( 10 ) as a way of ensuring
-
psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
April 24, 2018 - An additional timeout is undertaken prior to a new team beginning ensuring effective, efficient collaboration
-
psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
August 05, 2009 - of diverse populations, health care systems and providers should practice "universal precautions" by ensuring
-
psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
February 10, 2010 - Appropriate policies and procedures should assist facilities in ensuring patient safety.
-
psnet.ahrq.gov/web-mm/communication-consultants
October 01, 2018 - Communication With Consultants
Citation Text:
Cohn SL. Communication With Consultants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
-
psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - SPOTLIGHT CASE
Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations
Citation Text:
Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. PSNet [internet]. Rockville (MD): Agency for He…
-
psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - SPOTLIGHT CASE
False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.
Citation Text:
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …
-
psnet.ahrq.gov/issue/board-bedside-how-application-financial-structures-safety-and-quality-can-drive
January 29, 2015 - Study
From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system.
Citation Text:
Austin M, Demski R, Callender T, et al. From Board to Bedside: How the Application of Financial Structures to Safety and Q…
-
psnet.ahrq.gov/issue/electronic-patient-identification-sample-labeling-reduces-wrong-blood-tube-errors
September 20, 2012 - Study
Emerging Classic
Electronic patient identification for sample labeling reduces wrong blood in tube errors.
Citation Text:
Kaufman RM, Dinh A, Cohn CS, et al. Electronic patient identification for sample labeling reduces wrong blood in tube errors. Transfus…
-
psnet.ahrq.gov/issue/medical-problem-solving-analysis-clinical-reasoning
July 18, 2018 - Book/Report
Classic
Medical Problem Solving: An Analysis of Clinical Reasoning.
Citation Text:
Medical Problem Solving: An Analysis of Clinical Reasoning. Elstein AS, ed. Cambridge, MA: Harvard University Press; 1978. ISBN: 9780674561250.
Copy Citation
…
-
psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
December 01, 2012 - SPOTLIGHT CASE
"The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety
Citation Text:
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
-
psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - SPOTLIGHT CASE
Multifactorial Medication Mishap
Citation Text:
Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNot…
-
psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
June 01, 2003 - SPOTLIGHT CASE
Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care
Citation Text:
Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…
-
psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - The Inside of a Time Out
Citation Text:
Feldman DL. The Inside of a Time Out. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
-
psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
July 01, 2008 - This includes ensuring that appropriate metric scales (standing or weighted stretcher scales) are readily
-
psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - Ensuring structured inter-professional handoffs and closed-loop referrals are under-appreciated opportunities
-
psnet.ahrq.gov/web-mm/polypharmacy
March 01, 2007 - Polypharmacy
Citation Text:
Guglielmo JB. Polypharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
-
psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - These individuals play a vital role in ensuring the quality and safety of care; each may be the one to
-
psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
March 07, 2012 - The Commentary
Ensuring Safety With Liver Biopsy
The use of liver biopsy to obtain tumor or liver