-
psnet.ahrq.gov/web-mm/check-bags
January 03, 2017 - Check the Bags
Citation Text:
Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
-
psnet.ahrq.gov/node/49695/psn-pdf
October 01, 2013 - Finding Fault With the Default Alert
October 1, 2013
Baysari M. Finding Fault With the Default Alert. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/finding-fault-default-alert
The Case
A 33-year-old man with known refractory epilepsy and developmental delay was admitted to the hospital
after experiencing …
-
psnet.ahrq.gov/node/49700/psn-pdf
February 01, 2014 - Nonsustained Ventricular Tachycardia After Acute
Coronary Syndromes: Recognizing High-Risk Patients
February 1, 2014
Piccini JP, Newby KL, Califf R. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes:
Recognizing High-Risk Patients. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/nonsustaine…
-
psnet.ahrq.gov/node/49742/psn-pdf
September 01, 2015 - A Fumbled Handoff to Inpatient Rehab
September 1, 2015
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
The Case
An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…
-
psnet.ahrq.gov/node/49587/psn-pdf
May 01, 2009 - Missing Trauma
May 1, 2009
Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/missing-trauma
The Case
A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a
few minutes later by a customer, who immediately called 911. On arrival, para…
-
psnet.ahrq.gov/node/49473/psn-pdf
March 01, 2005 - On O.R. Off?
March 1, 2005
Leonard M. On O.R. Off? PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/or
The Case
An elderly man was admitted to the vascular surgery service with rest pain in his leg. Angiography
demonstrated peripheral artery disease with anatomy suitable for revascularization. A consulting
…
-
psnet.ahrq.gov/node/49727/psn-pdf
March 01, 2015 - Critical Opportunity Lost
March 1, 2015
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/critical-opportunity-lost
The Case
A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She
reported eating a heavy dinner the pre…
-
psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
January 31, 2024 - No matter how we measured skill on the front end or which outcome or aspect of quality we evaluated on
-
psnet.ahrq.gov/issue/creating-culture-safety-opioid-prescribing-handbook-healthcare-executives
May 01, 2023 - Toolkit
Creating a Culture of Safety for Opioid Prescribing: A Handbook for Healthcare Executives.
Citation Text:
Centers for Disease Control and Prevention (CDC); 2021. Creating a Culture of Safety for Opioid Prescribing: A Handbook for Healthcare Executives.
Copy Citation
Format:…
-
psnet.ahrq.gov/issue/opioid-taskforce-playbook
May 01, 2023 - Toolkit
Opioid Taskforce Playbook.
Citation Text:
College of Healthcare Information Management Executives; 2023. Opioid Taskforce Playbook.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Citation
…
-
psnet.ahrq.gov/node/840172/psn-pdf
November 16, 2022 - The Stoplight Mobility Alert System for safety and
prevention of falls in children with physical and cognitive
impairments.
November 16, 2022
Mullen JB, Wirt SZ, Moser A, et al. J Patient Saf. 2022;18(6):e947-e952
https://psnet.ahrq.gov/innovation/stoplight-mobility-alert-system-safety-and-prevention-fal…
-
psnet.ahrq.gov/node/39116/psn-pdf
April 30, 2014 - Diagnostic error in medicine: analysis of 583 physician-
reported errors.
April 30, 2014
Schiff G, Hasan O, Kim S, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors.
Arch Intern Med. 2009;169(20):1881-1887. doi:10.1001/archinternmed.2009.333.
https://psnet.ahrq.gov/issue/diagnostic-err…
-
psnet.ahrq.gov/issue/why-physicians-err-diagnosis
March 27, 2024 - Commentary
Why physicians err in diagnosis.
Citation Text:
Why physicians err in diagnosis. JAMA. 2015;313(12):1273. doi:10.1001/jama.2014.11660.
Copy Citation
Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downlo…
-
psnet.ahrq.gov/issue/spread-remains-challenge-patient-safety-improvement
January 23, 2019 - Newspaper/Magazine Article
'Spread' remains challenge in patient safety improvement.
Citation Text:
'Spread' remains challenge in patient safety improvement. Healthcare benchmarks and quality improvement. 2011;18(5):49-52.
Copy Citation
Format:
Google Scholar PubMed BibTe…
-
psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - All patients who are going to be treated with immunosuppressive drugs should be evaluated for risk factors
-
psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
April 01, 2008 - about improving communication, specifically seeking out and providing feedback once a patient has been evaluated
-
psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - may be needed to mitigate the possible effects of implicit bias on how post-procedural symptoms are evaluated
-
psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - However, this approach, while promising, has not been fully evaluated to determine its effectiveness
-
psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - was rounding with the attending, the resident was able to enter orders in real time as team members evaluated
-
psnet.ahrq.gov/node/837791/psn-pdf
August 05, 2022 - innovative ideas have been
generated in quality improvement and patient safety, yet we have not fully evaluated