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psnet.ahrq.gov/node/852698/psn-pdf
August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to
Increase Safety and Diagnostic Accuracy Innovation
August 30, 2023
https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-
diagnostic-accuracy
Summary
Addressing diagnostic errors to improve outcomes and patient safety h…
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psnet.ahrq.gov/node/866055/psn-pdf
May 29, 2024 - Reducing Preventable Patient Harm Due to Retained
Surgical Items: The RSI Bundle
May 29, 2024
https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
Summary
Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common
catego…
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psnet.ahrq.gov/web-mm/peripheral-iv-too-long
September 15, 2011 - SPOTLIGHT CASE
Peripheral IV in Too Long
Citation Text:
Fang C-T. Peripheral IV in Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML End…
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psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
July 17, 2024 - SPOTLIGHT CASE
Tough Call: Addressing Errors From Previous Providers
Citation Text:
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy…
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psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - Triple Handoff
September 1, 2006
Vidyarthi A. Triple Handoff. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/triple-handoff
Case Objectives
Appreciate the prevalence of handoffs and sign out related errors.
Understand the key elements of a safe and effective written and verbal sign out.
List Kotter’s 8 st…
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psnet.ahrq.gov/node/865412/psn-pdf
March 27, 2024 - Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
March 27, 2024
Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a
Psychiatric Presentation. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatmen…
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - Do Not Disturb!
October 1, 2007
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/do-not-disturb
Case Objectives
Define professionalism.
Discuss behaviors associated with lack of professionalism.
Outline steps one should take if a significant breach of professionalism is …
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Andrew P.J. …
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psnet.ahrq.gov/web-mm/transfusion-overload
September 23, 2020 - SPOTLIGHT CASE
Transfusion Overload
Citation Text:
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/node/841305/psn-pdf
January 27, 2023 - In Conversation with... Ellen Deutsch, MD, MS, FACS,
FAAP, FSSH, CPPS
December 14, 2022
In Conversation with.. Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
Editor’s Note: Ellen Deutsch, MD, MS, FACS, F…
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psnet.ahrq.gov/node/851870/psn-pdf
July 31, 2023 - In Conversation with... Regina Hoffman about Building
Capacity for Patient Safety
July 31, 2023
In Conversation with.. Regina Hoffman about Building Capacity for Patient Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
Editor’s no…
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psnet.ahrq.gov/issue/ihi-skilled-nursing-facility-trigger-tool-measuring-adverse-events
February 15, 2017 - November 21, 2016
Leadership Guide to Patient Safety: Resources and Tools for Establishing … July 12, 2017
Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era.
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psnet.ahrq.gov/node/41581/psn-pdf
August 08, 2012 - How-to Guides: Improving Transitions from the Hospital
to Reduce Avoidable Rehospitalizations.
August 8, 2012
Cambridge, MA: Institute for Healthcare Improvement; June 2012.
https://psnet.ahrq.gov/issue/how-guides-improving-transitions-hospital-reduce-avoidable-rehospitalizations
This series, developed in conjunct…
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psnet.ahrq.gov/issue/profiles-patient-safety-misplaced-femoral-line-guidewire-and-multiple-failures-detect-foreign
April 03, 2017 - December 21, 2022
Guide to Reducing Unintended Consequences of Electronic Health Records … Cancer
July 31, 2023
Preventing and mitigating radiology system failures: a guide
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psnet.ahrq.gov/issue/hospitalized-patients-understanding-their-plan-care
June 11, 2010 - View More
Related Resources
Patient-Centered Care Improvement Guide … February 18, 2011
Health Care Leader Action Guide to Reduce Avoidable Readmissions.
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psnet.ahrq.gov/issue/high-performance-work-systems-health-care-management-part-1-and-part-2
March 22, 2017 - March 22, 2017
Using Workforce Practices to Drive Quality Improvement: A Guide for Hospitals … June 23, 2010
Guide to Reducing Unintended Consequences of Electronic Health Records.
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psnet.ahrq.gov/issue/opportunities-and-recommendations-state-federal-coordination-improve-health-system
November 29, 2009 - Copy Citation
Related Resources From the Same Author(s)
2007 Guide to State … November 29, 2009
2014 Guide to State Adverse Event Reporting Systems.
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psnet.ahrq.gov/issue/quality-and-safety-nursing-competency-approach-improving-outcomes-second-edition
May 13, 2009 - August 9, 2013
The Improvement Guide: A Practical Approach to Enhancing Organizational … Perspective
June 1, 2016
Healthcare Safety for Nursing Personnel: An Organizational Guide
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psnet.ahrq.gov/issue/medication-safety-look-alike-sound-alike-medicines
November 19, 2014 - July 14, 2021
WHO Patient Safety Curriculum Guide: Multi-Professional Edition. … January 29, 2019
Caring for Those Who Care: Guide for the Development and Implementation
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psnet.ahrq.gov/issue/taking-national-action-prevent-and-eliminate-healthcare-associated-infections
May 06, 2015 - October 22, 2013
Guide to Patient and Family Engagement: Environmental Scan Report. … A Pharmacy Health Literacy Assessment Tool User's Guide.