-
psnet.ahrq.gov/node/39947/psn-pdf
July 03, 2014 - An accompanying editorial lauds this study as an example of how to conduct a rigorous, evidence-based
-
psnet.ahrq.gov/node/46424/psn-pdf
March 20, 2018 - This study is a rigorous example of how trigger tools can detect safety
hazards and improve timely cancer
-
psnet.ahrq.gov/node/47238/psn-pdf
October 13, 2018 - One such example is screening for lung cancer using low-dose computed tomography
(LDCT), which may benefit
-
psnet.ahrq.gov/node/35979/psn-pdf
September 17, 2010 - They provide a case-type example
of their suggested process to illustrate their framework.
-
psnet.ahrq.gov/node/42548/psn-pdf
December 29, 2014 - The studies had varying definitions of adverse events; for example, some did not include
geriatric syndromes
-
psnet.ahrq.gov/node/42361/psn-pdf
September 19, 2013 - While patients were observed engaging in safety behaviors—for
example, questioning the dose of a new
-
psnet.ahrq.gov/node/45190/psn-pdf
February 15, 2017 - For example, prior studies have postulated that a weekend effect
exists for patients with acute stroke
-
psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
June 14, 2023 - best supported prevention strategy in mechanically ventilated patients is oral hygiene; 22,23 for example
-
psnet.ahrq.gov/node/60242/psn-pdf
March 01, 2021 - For example, the team facilitates
consultation by a specialized geriatric inpatient team whenever a
-
psnet.ahrq.gov/node/851568/psn-pdf
July 31, 2023 - The best supported prevention strategy in mechanically
ventilated patients is oral hygiene;22,23 for example
-
psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - A simple example illustrates the importance of availability bias and how incorrect assumptions about
-
psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - removal of non-organic material need not be performed at the time of the initial evaluation. 10 A good example
-
psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
November 25, 2020 - For example, patients who are directly admitted for treatment of sepsis were found to have increased
-
psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
November 01, 2018 - areas that has been unappreciated is the set of opportunities to decrease handoffs, and this is an example
-
psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
November 01, 2018 - areas that has been unappreciated is the set of opportunities to decrease handoffs, and this is an example
-
psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
September 01, 2017 - EHR failure mode
Example
Health IT fails during use or is otherwise not working as designed.(
-
psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
January 01, 2021 - Spotlight
Spotlight
An Inadvertent Bolus of Norepinephrine
Source and Credits
• This presentation is based on the May 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarina Fazio, PhD, RN, Emma Blackmon, PhD,
RN, Amy Doroy, PhD,…
-
psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
September 01, 2017 - EHR failure mode
Example
Health IT fails during use or is otherwise not working as designed.(
-
psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - SPOTLIGHT CASE
The Risks of a Malpositioned Gastrostomy Tube and Poor Communication
Citation Text:
Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
-
psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx
Spotlight
The Risks of a Malpositioned Gastrostomy Tube and
Poor Communication
Source and Credits
• This presentation is based on the November 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahr…