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psnet.ahrq.gov/node/848125/psn-pdf
April 26, 2023 - Surveillance Monitoring to Improve Patient Safety in
Acute Hospital Care Units
April 26, 2023
McGrath S, Blike G, Gale B, et al. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care
Units. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-…
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psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - An Easily Forgotten Tube
Citation Text:
Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
July 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case July 2007
Resuscitation Errors:
A Shocking Problem
Source and Credits
This presentation is based on the July 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Benjamin Abella, MD, MPhil, …
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psnet.ahrq.gov/node/49484/psn-pdf
June 01, 2005 - Two Pills, Same Drug
June 1, 2005
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/two-pills-same-drug
The Case
A 34-year-old woman with AIDS developed a fever and hypotension due to suspected pneumonia. Her past
medical history included several AIDS-related complica…
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psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable
Citation Text:
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33666/psn-pdf
October 01, 2008 - Methicillin-Resistant Staphylococcus aureus
April 1, 2008
Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
Perspective
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media …
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psnet.ahrq.gov/node/49713/psn-pdf
June 01, 2014 - CVC Removal: A Procedure Like Any Other
June 1, 2014
Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
The Case
A 27-year-old man with a history of Behçet disease and recurrent liver abscesses was admitted to the
hospital for a p…
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psnet.ahrq.gov/node/49670/psn-pdf
November 01, 2012 - Missed Pneumonia
November 1, 2012
Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/missed-pneumonia
The Case
A 32-year-old man presented to the emergency department (ED) with 3 days of fever and right pleuritic
chest pain. Review of systems was negative for cough or dy…
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psnet.ahrq.gov/node/49517/psn-pdf
August 01, 2006 - Miscalculated Risk
August 1, 2006
Strassels SA. Miscalculated Risk. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/miscalculated-risk
The Case
A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after lifting his 2-
week-old infant. He received Vicodin (hydrocodone and a…
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psnet.ahrq.gov/node/46304/psn-pdf
November 01, 2017 - Comparative performance of pediatric weight estimation
techniques: a human factor errors analysis.
November 1, 2017
Abdel-Rahman SM, Jacobsen R, Watts JL, et al. Comparative performance of pediatric weight estimation
techniques: a human factor errors analysis. Pediatr Emerg Care. 2015;33(8):548-552.
doi:10.1097/pe…
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psnet.ahrq.gov/node/34680/psn-pdf
February 09, 2011 - Estimating hospital deaths due to medical errors:
preventability is in the eye of the reviewer.
February 9, 2011
Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the
reviewer. JAMA. 2001;286(4):415-20.
https://psnet.ahrq.gov/issue/estimating-hospital-deaths-du…
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psnet.ahrq.gov/node/41069/psn-pdf
February 21, 2012 - Using the opportunity estimator tool to improve
engagement in a quality and safety intervention.
February 21, 2012
Duval-Arnould J, Mathews SC, Weeks K, et al. Using the Opportunity Estimator tool to improve
engagement in a quality and safety intervention. Jt Comm J Qual Patient Saf. 2012;38(1):41-47, 1.
https://p…
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psnet.ahrq.gov/node/41251/psn-pdf
March 29, 2012 - Patient safety in developing countries: retrospective
estimation of scale and nature of harm to patients in
hospital.
March 29, 2012
Wilson R, Michel P, Olsen S, et al. Patient safety in developing countries: retrospective estimation of scale
and nature of harm to patients in hospital. BMJ. 2012;344:e832. doi:10.1…
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psnet.ahrq.gov/node/46116/psn-pdf
May 24, 2017 - Elimination of emergency department medication errors
due to estimated weights.
May 24, 2017
Greenwalt M, Griffen D, Wilkerson J. Elimination of Emergency Department Medication Errors Due To
Estimated Weights. BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u214416.w5476.
https://psnet.ahrq.gov/issue/elimin…
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psnet.ahrq.gov/node/43192/psn-pdf
December 15, 2014 - Using estimated true safety event rates versus flagged
safety event rates: does it change hospital profiling and
payment?
December 15, 2014
Rosen AK, Chen Q, Borzecki A, et al. Using estimated true safety event rates versus flagged safety event
rates: does it change hospital profiling and payment? Health Serv Res.…
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psnet.ahrq.gov/node/40641/psn-pdf
July 27, 2011 - Error in body weight estimation leads to inadequate
parenteral anticoagulation.
July 27, 2011
Macedo LG dos R, de Oliveira L, Pintão MC, et al. Error in body weight estimation leads to inadequate
parenteral anticoagulation. Am J Emerg Med. 2011;29(6):613-7. doi:10.1016/j.ajem.2010.01.006.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/39787/psn-pdf
August 25, 2010 - National estimates of adverse events during
nonpsychiatric hospitalizations for persons with
schizophrenia.
August 25, 2010
Khaykin E, Ford DE, Pronovost P, et al. National estimates of adverse events during nonpsychiatric
hospitalizations for persons with schizophrenia. Gen Hosp Psychiatry. 2010;32(4):419-25.
do…
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psnet.ahrq.gov/node/34918/psn-pdf
December 17, 2009 - Racial, ethnic, and socioeconomic disparities in estimates
of AHRQ patient safety indicators.
December 17, 2009
Coffey RM, Andrews RM, Moy E. Racial, ethnic, and socioeconomic disparities in estimates of AHRQ
patient safety indicators. Med Care. 2005;43(3 Suppl):I48-I57.
https://psnet.ahrq.gov/issue/racial-ethnic-…
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psnet.ahrq.gov/node/38600/psn-pdf
October 03, 2017 - Assessment of transparency of cost estimates in
economic evaluations of patient safety programmes.
October 3, 2017
Fukuda H, Imanaka Y. Assessment of transparency of cost estimates in economic evaluations of patient
safety programmes. J Eval Clin Pract. 2009;15(3):451-9. doi:10.1111/j.1365-2753.2008.01033.x.
https…
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psnet.ahrq.gov/node/43075/psn-pdf
August 02, 2015 - National estimates of insulin-related hypoglycemia and
errors leading to emergency department visits and
hospitalizations.
August 2, 2015
Geller AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related hypoglycemia and errors
leading to emergency department visits and hospitalizations. JAMA Intern …