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psnet.ahrq.gov/issue/empowering-frontline-nurses-structured-intervention-enables-nurses-improve-medication
March 13, 2012 - Study
Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.
Citation Text:
Kliger J, Blegen MA, Gootee D, et al. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accur…
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psnet.ahrq.gov/issue/national-patient-safety-curriculum-pediatric-emergency-medicine
January 12, 2022 - Study
A national patient safety curriculum in pediatric emergency medicine.
Citation Text:
Stankovic C, Wolff M, Chang TP, et al. A National Patient Safety Curriculum in Pediatric Emergency Medicine. Pediatr Emerg Care. 2019;35(8):519-521. doi:10.1097/PEC.0000000000001533.
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psnet.ahrq.gov/issue/moral-distress-intensive-care-unit-personnel-not-consistently-associated-adverse-medication
November 02, 2010 - Study
Moral distress in intensive care unit personnel is not consistently associated with adverse medication events and other adverse events
Citation Text:
Dodek P, Norena M, Ayas N, et al. Moral distress in intensive care unit personnel is not consistently associated with adverse medica…
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psnet.ahrq.gov/issue/use-prospective-risk-analysis-method-improve-safety-cancer-chemotherapy-process
May 29, 2019 - Study
Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process.
Citation Text:
Bonnabry P, Cingria L, Ackermann M, et al. Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process. Int J Qual Health Care…
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psnet.ahrq.gov/issue/residents-numeric-inputting-error-computerized-physician-order-entry-prescription
March 24, 2019 - Study
Residents' numeric inputting error in computerized physician order entry prescription.
Citation Text:
Wu X, Wu C, Zhang K, et al. Residents' numeric inputting error in computerized physician order entry prescription. Int J Med Inform. 2016;88:25-33. doi:10.1016/j.ijmedinf.2016.01.0…
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psnet.ahrq.gov/issue/understanding-attitudes-hospital-pharmacists-reporting-medication-incidents-qualitative-study
September 04, 2016 - Study
Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study.
Citation Text:
Williams SD, Phipps D, Ashcroft DM. Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study. Res Social Adm…
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psnet.ahrq.gov/issue/quality-initiative-decrease-pathology-specimen-labeling-errors-using-radiofrequency
August 28, 2017 - Study
A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center.
Citation Text:
Francis DL, Prabhakar S, Sanderson SO. A quality initiative to decrease pathology specimen-labeling errors using radiofrequenc…
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psnet.ahrq.gov/issue/adverse-events-are-common-intensive-care-unit-results-structured-record-review
January 28, 2010 - Study
Adverse events are common on the intensive care unit: results from a structured record review.
Citation Text:
Nilsson L, Pihl A, Tågsjö M, et al. Adverse events are common on the intensive care unit: results from a structured record review. Acta Anaesthesiol Scand. 2012;56(8):959…
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psnet.ahrq.gov/issue/improving-quality-drug-error-reporting
December 21, 2016 - Study
Improving the quality of drug error reporting.
Citation Text:
Armitage G, Newell R, Wright J. Improving the quality of drug error reporting. J Eval Clin Pract. 2010;16(6):1189-97. doi:10.1111/j.1365-2753.2009.01293.x.
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DOI Google Scholar PubMed …
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psnet.ahrq.gov/issue/medical-error-reporting-patient-safety-and-physician
February 04, 2009 - Study
Medical error reporting, patient safety, and the physician.
Citation Text:
Anderson B, Stumpf PG, Schulkin J. Medical Error Reporting, Patient Safety, and the Physician. J Patient Saf. 2009;5(3):176-179. doi:10.1097/pts.0b013e3181b320b0.
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DOI Go…
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - Studies
evaluating mortality and other benefits of PERT are mixed.7,41,42 Advantages include shortened
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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/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/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - SPOTLIGHT CASE
Don't Dismiss the Dangerous: Obstetric Hemorrhage
Citation Text:
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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…
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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - SPOTLIGHT CASE
Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy
Citation Text:
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…
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psnet.ahrq.gov/issue/special-issue-health-information-technology
August 22, 2007 - June 29, 2022
Scoping review of studies evaluating frailty and its association with medication
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psnet.ahrq.gov/issue/digital-healthcare-research
December 24, 2008 - August 19, 2020
Novel, High-Impact Studies Evaluating Health System and Healthcare Professional
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psnet.ahrq.gov/issue/grants-line-database-gold
December 24, 2008 - September 22, 2021
Novel, High-Impact Studies Evaluating Health System and Healthcare
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psnet.ahrq.gov/issue/hospital-mistakes-kept-secret
September 30, 2009 - June 21, 2017
Medication safety at the interface: evaluating risks associated with discharge