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psnet.ahrq.gov/primer/clinical-decision-support-systems
December 15, 2024 - Clinical Decision Support Systems
Citation Text:
Clinical Decision Support Systems. 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/33570/psn-pdf
June 15, 2024 - Diagnostic Errors
June 15, 2024
Diagnostic Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/diagnostic-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 20…
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psnet.ahrq.gov/node/49491/psn-pdf
September 01, 2005 - Time of Death?
September 1, 2005
Taekman JM, Wright MC. Time of Death? PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/time-death
The Case
An 80-year-old woman with multiple illnesses, including chronic obstructive pulmonary disease (COPD),
was found pulseless and cyanotic in her hospital bed. A code was ca…
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psnet.ahrq.gov/node/49843/psn-pdf
October 01, 2018 - Spotlight: Overdiagnosis and Delay: Challenges in Sepsis
Diagnosis
October 1, 2018
Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
Case Objectives
Realize the im…
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
January 01, 2024 - Spotlight
Spotlight
Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head
1
Source and Credits
This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Ryan Martin, MD, FCNS and …
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psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
April 26, 2023 - Annual Perspective
Technology as a Tool for Improving Patient Safety
A Jay Holmgren, Susan McBride,Bryan Gale, Sarah Mossburg
| March 29, 2023
View more articles from the same authors.
Citation Text:
Holmgren AJ, McBride S, Gale B, et al. Technology as a …
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
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May 29, 2024
View more articles from the same authors.
Inno…
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psnet.ahrq.gov/node/846564/psn-pdf
March 29, 2023 - Technology as a Tool for Improving Patient Safety
March 29, 2023
Holmgren AJ, McBride S, Gale B, et al. Technology as a Tool for Improving Patient Safety . PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
Introduction
In the past several decades, technological a…
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions
Citation Text:
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
December 02, 2020 - SPOTLIGHT CASE
The Lost Start Date: an Unknown Risk of E-prescribing
Citation Text:
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. 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/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - SPOTLIGHT CASE
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
Citation Text:
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…
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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
June 01, 2003 - SPOTLIGHT CASE
Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care
Citation Text:
Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format: …
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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - SPOTLIGHT CASE
Cognitive Overload in the ICU
Citation Text:
Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - Hidden Danger! Insidious Postpartum Bleeding After
Emergency Cesarean Delivery.
November 30, 2021
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean
Delivery. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emerg…
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psnet.ahrq.gov/node/49753/psn-pdf
February 01, 2016 - Robotic Surgery: Risks vs. Rewards
February 1, 2016
Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
Case Objectives
Discuss the background and current trends in robotic surgery.
Identify the benefits of robotic s…
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psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
October 28, 2020 - SPOTLIGHT CASE
Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis
Citation Text:
Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/time-death
January 03, 2017 - Time of Death?
Citation Text:
Taekman JM, Wright MC. Time of Death?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare
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psnet.ahrq.gov/node/49667/psn-pdf
October 01, 2012 - Looking for Meds in All the Wrong Places
October 1, 2012
Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
The Case
A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She
went to t…