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psnet.ahrq.gov/issue/fostering-patient-safety-competencies-using-multiple-patient-simulation-experiences
January 12, 2022 - Study
Fostering patient safety competencies using multiple-patient simulation experiences.
Citation Text:
Ironside PM, Jeffries PR, Martin A. Fostering patient safety competencies using multiple-patient simulation experiences. Nurs Outlook. 2009;57(6):332-7. doi:10.1016/j.outlook.2009.0…
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psnet.ahrq.gov/issue/educational-intervention-contextualizing-patient-care-and-medical-students-abilities-probe
March 02, 2016 - Study
An educational intervention for contextualizing patient care and medical students' abilities to probe for contextual issues in simulated patients.
Citation Text:
Schwartz A, Weiner SJ, Harris IB, et al. An educational intervention for contextualizing patient care and medical studen…
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psnet.ahrq.gov/issue/improving-documentation-beta-blocker-quality-measure-through-anesthesia-information
June 23, 2009 - Study
Improving documentation of a beta-blocker quality measure through an anesthesia information management system and real-time notification of documentation errors.
Citation Text:
Nair BG, Peterson GN, Newman S-F, et al. Improving documentation of a beta-blocker quality measure throug…
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psnet.ahrq.gov/issue/utilization-pharmacy-technicians-increase-accuracy-patient-medication-histories-obtained
October 08, 2014 - Study
Utilization of pharmacy technicians to increase the accuracy of patient medication histories obtained in the emergency department.
Citation Text:
Rubin EC, Pisupati R, Nerenberg SF. Utilization of Pharmacy Technicians to Increase the Accuracy of Patient Medication Histories Obtaine…
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psnet.ahrq.gov/node/35905/psn-pdf
June 23, 2009 - Promethazine HCl (marketed as Phenergan) Information.
June 23, 2009
FDA; Food and Drug Administration; CDER; Center for Drug Evaluation and Research
https://psnet.ahrq.gov/issue/promethazine-hcl-marketed-phenergan-information
This alert highlights the dangers of administering promethazine hydrochloride to young chi…
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psnet.ahrq.gov/node/42292/psn-pdf
May 22, 2013 - Leapfrog hospital safety scores 'depressing.'
May 22, 2013
Clark C. HealthLeaders Media. May 9, 2013.
https://psnet.ahrq.gov/issue/leapfrog-hospital-safety-scores-depressing
This news piece reports on a national evaluation of hospitals that found little improvement in safety in the
profiled health care systems.
h…
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psnet.ahrq.gov/node/35883/psn-pdf
July 01, 2009 - Bar Code Label Requirements for Blood and Blood
Components.
July 1, 2009
FDA; Food and Drug Administration; CBER; Center for Biologics Evaluation and Research.
https://psnet.ahrq.gov/issue/bar-code-label-requirements-blood-and-blood-components
This FAQ answers questions related to the FDA machine-readable bar-codi…
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psnet.ahrq.gov/node/37492/psn-pdf
March 18, 2010 - Insight into preventing wrong-site surgery.
March 18, 2010
PA PSRS Patient Saf Advis 2007 Dec;4(4):109,112-23.
https://psnet.ahrq.gov/issue/insight-preventing-wrong-site-surgery
This article summarizes a state-level analysis that used site visits along with near miss and error reports to
evaluate wrong-site surger…
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psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
June 14, 2023 - during CPR. 6
In 2015, and again in 2019, the International Liaison Committee on Resuscitation (ILCOR) evaluated
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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - Since use of restraints is a very emotional issue and would be evaluated in hindsight,
providers may
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.72_slideshow.ppt
September 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case September 2004
Poor Prognosis?
Source and Credits
This presentation is based on the September 2004
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Elizabeth B. Lamont, M…
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psnet.ahrq.gov/node/49752/psn-pdf
January 01, 2016 - Inadvertent Use of More Potent Acid Leads to Burn
January 1, 2016
Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
The Case
A 31-year-old woman came to the clinic for a routine well-woman evaluation. She…
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psnet.ahrq.gov/issue/characteristics-and-predictors-missed-opportunities-lung-cancer-diagnosis-electronic-health
January 19, 2012 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/diagnostic-errors-musculoskeletal-oncology-and-possible-mitigation-strategies
May 01, 2013 - December 27, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung-cancer
March 28, 2012 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/evaluation-12-strategies-obtaining-second-opinions-improve-interpretation-breast
November 03, 2015 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/patient-safety-leadership-academy-university-pennsylvania-first-cohorts-learning-experience
October 04, 2011 - June 18, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/missed-lesions-abdominal-oncologic-ct-lessons-learned-quality-assurance
April 21, 2011 - October 4, 2011
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/delayed-or-missed-diagnosis-cervical-spine-injuries
May 05, 2010 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.