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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…
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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…
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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
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.236_slideshow.ppt
March 01, 2011 - Spotlight Case July 2008
Spotlight Case March 2011
Volume Too Low: In and Out
Pediatric Patient Safety
*
*
Source and Credits
This presentation is based on the March 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Marlene Miller, MD, MSc…
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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…
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - Take-Home Points
Despite the frequency of breast complaints, evaluating a breast lump is a beguilingly
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psnet.ahrq.gov/node/33759/psn-pdf
October 01, 2012 - A hospital using all of these measures
would, however, only scratch the surface of evaluating the quality
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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.
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Format:…
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Citation
…
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psnet.ahrq.gov/node/845356/psn-pdf
March 29, 2023 - A novel approach for engagement in team training in
high-technology surgery: the robotic-assisted surgery
olympics.
March 29, 2023
Cohen TN, Anger JT, Kanji FF, et al. A novel approach for engagement in team training in high-technology
surgery: the robotic-assisted surgery olympics. J Patient Saf. 2022;18(6):570-5…
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psnet.ahrq.gov/node/42099/psn-pdf
March 13, 2013 - Inpatient fall prevention programs as a patient safety
strategy: a systematic review.
March 13, 2013
Miake-Lye IM, Hempel S, Ganz DA, et al. Inpatient fall prevention programs as a patient safety strategy: a
systematic review. Ann Intern Med. 2013;158(5 Pt 2):390-396. doi:10.7326/0003-4819-158-5-201303051-
00005.
…
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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…
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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…
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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.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downlo…
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psnet.ahrq.gov/node/44026/psn-pdf
November 03, 2015 - Effect of a postdischarge virtual ward on readmission or
death for high-risk patients: a randomized clinical trial.
November 3, 2015
Dhalla IA, O'Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high-
risk patients: a randomized clinical trial. JAMA. 2014;312(13):1305-12. …
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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.
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Format:
Google Scholar PubMed BibTe…
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - Rhew T, Harris S, Degenkolb K, et al. 726: EVALUATING THE SAFETY AND EFFICACY OF LORAZEPAM CONTINUOUS
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psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
September 22, 2010 - Inappropriate Antibiotic Use
Citation Text:
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line
Citation Text:
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google Scholar …
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psnet.ahrq.gov/node/49402/psn-pdf
June 01, 2003 - Inappropriate Antibiotic Use
June 1, 2003
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
The Case
A 41-year-old woman presented to the hospital with acute renal failure, which came to be diagnosed as a
first presentation of s…