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psnet.ahrq.gov/issue/verbal-medication-orders-or
March 06, 2024 - Commentary
Verbal medication orders in the OR.
Citation Text:
Hendrickson T. Verbal medication orders in the OR. AORN J. 2007;86(4):626-9.
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psnet.ahrq.gov/issue/standardizing-hospital-discharge-planning-mayo-clinic
October 19, 2022 - Study
Standardizing hospital discharge planning at the Mayo Clinic.
Citation Text:
Holland DE, Hemann MA. Standardizing hospital discharge planning at the Mayo Clinic. Jt Comm J Qual Patient Saf. 2011;37(1):29-36.
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psnet.ahrq.gov/issue/isnt-my-information-impact-accurate-identity-management-patient-safety
January 29, 2020 - Newspaper/Magazine Article
This isn't my information! The impact of accurate identity management on patient safety.
Citation Text:
Garcia R. This isn't my information! The impact of accurate identity management on patient safety. Health management technology. 2013;34(3):10-1.
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psnet.ahrq.gov/issue/how-reliable-your-hospital-qualitative-framework-analysing-reliability-levels
October 19, 2022 - Commentary
How reliable is your hospital? A qualitative framework for analysing reliability levels.
Citation Text:
Ikkersheim DE, Berg M. How reliable is your hospital? A qualitative framework for analysing reliability levels. BMJ Qual Saf. 2011;20(9):785-790.
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psnet.ahrq.gov/issue/misinformation-medical-literature-what-role-do-error-and-fraud-play
November 02, 2011 - Commentary
Misinformation in the medical literature: what role do error and fraud play?
Citation Text:
Steen G. Misinformation in the medical literature: what role do error and fraud play? J Med Ethics. 2011;37(8):498-503. doi:10.1136/jme.2010.041830.
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psnet.ahrq.gov/issue/how-avoid-paediatric-medication-errors-users-guide-literature
May 26, 2011 - Review
How to avoid paediatric medication errors: a user's guide to the literature.
Citation Text:
Walsh KE, Kaushal R, Chessare JB. How to avoid paediatric medication errors: a user's guide to the literature. Arch Dis Child. 2005;90(7):698-702.
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psnet.ahrq.gov/issue/recurrent-wrong-route-drug-error-professional-shame
July 22, 2020 - Commentary
Recurrent wrong-route drug error – a professional shame.
Citation Text:
Bell D. Recurrent wrong-route drug error - a professional shame. Anaesthesia. 2007;62(6):541-5.
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psnet.ahrq.gov/issue/removing-me-md
July 18, 2016 - Commentary
Removing the "me" from "MD."
Citation Text:
Parikh RB. Removing the “Me” From “MD”. JAMA. 2013;310(18). doi:10.1001/jama.2013.280722.
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psnet.ahrq.gov/issue/disclosure-medical-errors-right-thing-do
September 13, 2010 - Commentary
Disclosure of medical errors: the right thing to do.
Citation Text:
Schuer KM, AAPA QCC of the. Disclosure of medical errors: the right thing to do. JAAPA. 2010;23(8):27-9.
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psnet.ahrq.gov/issue/embedding-quality-improvement-and-patient-safety-ucla-value-analysis-experience
October 02, 2019 - Commentary
Embedding quality improvement and patient safety - the UCLA value analysis experience.
Citation Text:
Gambone JC, Broder MS. Embedding quality improvement and patient safety: the UCLA value analysis experience. Best Pract Res Clin Obstet Gynaecol. 2007;21(4):581-92.
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psnet.ahrq.gov/issue/ambiguities-chronic-illness-management-and-challenges-medical-error-paradigm
July 02, 2014 - Study
Ambiguities of chronic illness management and challenges to the medical error paradigm.
Citation Text:
Lutfey KE, Freese J. Ambiguities of chronic illness management and challenges to the medical error paradigm. Soc Sci Med. 2007;64(2):314-25.
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psnet.ahrq.gov/issue/disclosing-adverse-events-you-said-it-now-write-it
July 14, 2010 - Commentary
Disclosing adverse events: you said it, now write it.
Citation Text:
Monson MS. Disclosing adverse events: you said it, now write it. Nurs Manage. 2006;37(8):16-7, 55.
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - SPOTLIGHT CASE
A Missed Bowel Perforation - the Importance of Diagnostic Reasoning
Citation Text:
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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psnet.ahrq.gov/node/853902/psn-pdf
September 27, 2023 - A Missed Bowel Perforation - the Importance of
Diagnostic Reasoning
September 27, 2023
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
Disclosure of …
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psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - Triggers and Trigger Tools
Citation Text:
Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/867004/psn-pdf
October 30, 2024 - Critical Radiology Alert Process
October 30, 2024
https://psnet.ahrq.gov/innovation/critical-radiology-alert-process
Summary
Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of
unrelated abnormal findings and provides a companion follow-up process, with the goal o…
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psnet.ahrq.gov/node/49524/psn-pdf
November 01, 2006 - Secured But Not Always Safe
November 1, 2006
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/secured-not-always-safe
The Case
An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative
osteoarthritis. She received spinal …
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psnet.ahrq.gov/node/33641/psn-pdf
November 01, 2006 - Human Factors Engineering Can Teach You How to Be
Surprised Again
November 1, 2006
Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
Perspective
Certain phrases ar…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.131_slideshow.ppt
August 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case August 2006
Physical Diagnosis: A Lost Art?
Source and Credits
This presentation is based on the August 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: George Thompson III,…
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psnet.ahrq.gov/web-mm/managing-care-challenges-group-home-setting-staffing-adequate-unplanned-incidents
April 27, 2022 - Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?
Citation Text:
Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…