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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
November 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case November 2008
Dangerous Shift
Source and Credits
This presentation is based on the November 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Emily S. Patterson, PhD
Institute for Ergonomics, Ohi…
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psnet.ahrq.gov/node/49689/psn-pdf
August 21, 2013 - Anesthesia: A Weighty Issue
August 21, 2013
Sinha AC. Anesthesia: A Weighty Issue. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/anesthesia-weighty-issue
The Case
A 77-year-old woman was evaluated preoperatively in anticipation of an elective left hip arthroplasty. She
reported having a history of hyperte…
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psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
November 01, 2023 - Inadvertent Use of More Potent Acid Leads to Burn
Citation Text:
Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar B…
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psnet.ahrq.gov/node/49416/psn-pdf
September 01, 2003 - Check the Bags
September 1, 2003
Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/check-bags
The Case
A 50-year-old man with new atrial fibrillation was placed on a diltiazem drip in the emergency department
for rate control. After arriving at the cardiac care unit (CCU…
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psnet.ahrq.gov/web-mm/cultural-dimensions-depression
September 01, 2018 - Cultural Dimensions of Depression
Citation Text:
Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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psnet.ahrq.gov/node/33739/psn-pdf
October 01, 2012 - The Physical Environment: An Often Unconsidered
Patient Safety Tool
October 1, 2012
Joseph A, Malone EB. The Physical Environment: An Often Unconsidered Patient Safety Tool. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
Perspective
Now that…
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psnet.ahrq.gov/node/49837/psn-pdf
August 01, 2018 - Abdominal Aortic Aneurysm Screening
August 1, 2018
Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
Case Objectives
Describe risk factors associated with abdominal aortic aneurysm.
Identify patient populations meeting criteria fo…
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psnet.ahrq.gov/web-mm/air-side-caution
April 21, 2015 - Air on the Side of Caution
Citation Text:
Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - 40 of K
November 1, 2003
Lesar TS. 40 of K. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/40-k
The Case
An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve
replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
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psnet.ahrq.gov/web-mm/critical-opportunity-lost
February 17, 2017 - Critical Opportunity Lost
Citation Text:
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - Evaluating the patient safety indicators: how well do they perform on Veterans Health Administration … Sections
Perspective
Related Resources From the Same Author(s)
Evaluating
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psnet.ahrq.gov/perspective/adverse-events-dentistry
December 22, 2020 - opportunities exist to consider how to improve patient safety in this care setting. 1
Barriers to Evaluating … PubMedId RIS
Download Citation
Sections
Introduction
Barriers to Evaluating
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - Evaluating the knowledge of endotracheal cuff pressure monitoring among critical care providers by palpation
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psnet.ahrq.gov/node/843051/psn-pdf
February 01, 2023 - Evaluating risk factors for re-exploration due to
postoperative neck hematoma after thyroid surgery:
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psnet.ahrq.gov/node/867599/psn-pdf
January 22, 2025 - Assessing patient work system factors for medication
management during transition of care among older
adults: an observational study.
January 22, 2025
Xiao Y, Hsu Y-J, Hannum SM, et al. Assessing patient work system factors for medication management
during transition of care among older adults: an observational st…
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psnet.ahrq.gov/node/865344/psn-pdf
March 27, 2024 - Use of computerized physician order entry with clinical
decision support to prevent dose errors in pediatric
medication orders: a systematic review.
March 27, 2024
Ruutiainen H, Holmström A-R, Kunnola E, et al. Use of computerized physician order entry with clinical
decision support to prevent dose errors in pedia…
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psnet.ahrq.gov/node/73445/psn-pdf
June 30, 2021 - Moving beyond the weekend effect: how can we best
target interventions to improve patient care?
June 30, 2021
Marang-van de Mheen PJ, Vincent CA. Moving beyond the weekend effect: how can we best target
interventions to improve patient care? BMJ Qual Saf. 2021;30(7):525-528. doi:10.1136/bmjqs-2020-
012620.
https:…
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psnet.ahrq.gov/node/45538/psn-pdf
December 14, 2016 - Liquid medication errors and dosing tools: a randomized
controlled experiment.
December 14, 2016
Yin S, Parker RM, Sanders LM, et al. Liquid Medication Errors and Dosing Tools: A Randomized Controlled
Experiment. Pediatrics. 2016;138(4):e20160357.
https://psnet.ahrq.gov/issue/liquid-medication-errors-and-dosing-to…
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psnet.ahrq.gov/node/73287/psn-pdf
May 19, 2021 - Influence of opioid prescription policy on overdoses and
related adverse effects in a primary care population.
May 19, 2021
Harder VS, Plante TB, Koh I, et al. Influence of opioid prescription policy on overdoses and related adverse
effects in a primary care population. J Gen Intern Med. 2021;36(7):2013-2020. doi:1…
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psnet.ahrq.gov/node/73978/psn-pdf
October 20, 2021 - Preventing pregnancy-related mental health deaths:
insights from 14 US maternal mortality review
committees, 2008-17.
October 20, 2021
Trost SL, Beauregard JL, Smoots AN, et al. Preventing pregnancy-related mental health deaths: insights
from 14 US maternal mortality review committees, 2008-17. Health Aff (Millwoo…