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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - In addition, delayed diagnosis due to access barriers continues to happen frequently.
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - Communications with the pharmacy and between providers may not happen consistently due to time constraints
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psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
June 01, 2018 - I see this beginning to happen in medical schools, residencies, medical and professional organizations
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psnet.ahrq.gov/node/60721/psn-pdf
July 21, 2020 - because all the restrictions on telehealth have been
suspended, but it's unclear what is going to happen
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - Before this could happen, the patient developed increasing hypoxemia and respiratory distress, ultimately
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psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - However, without a dietician available, this notification did not happen,
which necessitated the ordering
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psnet.ahrq.gov/node/863649/psn-pdf
February 28, 2024 - It is easy to talk about how
communication should happen, for example, in a surgery unit in a hospital
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psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - Today, this doesn't happen.
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - If we're not going to reimburse, it's just not going to happen. … this is what works, we will need to figure out the financial models, logistically how you make this happen
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psnet.ahrq.gov/node/849661/psn-pdf
June 28, 2023 - standard preoperative huddle and pre-incision checklist likely
contributed to this near miss, which may happen
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - standard preoperative huddle and pre-incision checklist likely contributed to this near miss, which may happen
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - SPOTLIGHT CASE
Signout Fallout
Citation Text:
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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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.
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psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
December 07, 2009 - SPOTLIGHT CASE
No News May Not Be Good News
Citation Text:
Moore CR. No News May Not Be Good News. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?
Citation Text:
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
C…
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psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
August 04, 2021 - Transitions in Adolescent Medicine
Citation Text:
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - SPOTLIGHT CASE
Out of Sight, Out of Mind: Out-of-Office Test Result Management
Citation Text:
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
…
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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - SPOTLIGHT CASE
Order Interrupted by Text: Multitasking Mishap
Citation Text:
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
…
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - SPOTLIGHT CASE
Transfer Troubles
Citation Text:
Hains IM. Transfer Troubles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - Getting a Good Report Card: Unintended Consequences
of the Public Reporting of Hospital Quality
November 1, 2006
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of
Hospital Quality. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…