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psnet.ahrq.gov/node/33674/psn-pdf
February 01, 2009 - In Conversation with…Robert M. Wachter, MD
October 1, 2008
In Conversation with…Robert M. Wachter, MD. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
Editor's note: At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and
Chief of the…
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psnet.ahrq.gov/node/49712/psn-pdf
June 01, 2014 - May I Have Another?—Medication Error
June 1, 2014
Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
The Case
A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a
pharmacology-tra…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.281_slideshow.ppt
October 01, 2012 - Spotlight Case July 2008
Spotlight Case
CA-MRSA Skin Infections:
An Ounce of Prevention is Worth a Pound of Cure
*
*
Source and Credits
This presentation is based on the October 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Catherine L…
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - This perspective includes the contribution of Dr. … Graber’s pioneering work on diagnostic error in 2005, which includes an identification of systemic problems … Clinical decision making is a complex process that includes a variety of factors. … Clinician-centered misdiagnosis is only a part of overall diagnostic safety; the NASEM definition also includes … guidance that scales to particular needs at the level of individual practitioner whose scope of work includes
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psnet.ahrq.gov/node/60548/psn-pdf
May 28, 2020 - ’ve expanded the scope of what we view as “critical” for assuring the safety of products, and that
includes … This includes our Breakthrough Devices Program, which covers
devices intended to treat or diagnose life … This includes our work establishing
medical device registries, our increasing work with industry, and
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - A Postpartum Woman with an Erroneous SARS-CoV-2 Test
Citation Text:
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citation
Forma…
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psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety
Ronen Rozenblum, MD, MPH, and David Bates, MD, MS | November 1, 2017
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Rozenblum R, Bates DW. The Role…
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psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety
Robert M. Wachter, MD | September 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wachter R. Playing Well with Others: "Translocational Research" in…
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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - Sleep Deprivation Leads to Medication Error During
Spinal Epidural Anesthesia
August 30, 2023
Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-…
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia
Citation Text:
Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - Interpreting the Patient Safety Literature
Kaveh G. Shojania, MD | June 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/node/47328/psn-pdf
January 01, 2020 - The program measures HAC rates by a composite Patient Safety
Indicator (PSI90), which includes 10 specific
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psnet.ahrq.gov/node/60174/psn-pdf
March 30, 2020 - Most notably, this third edition includes
a chapter on cross-cutting topics that are not related to … , diagnostic errors, delirium, adverse drug events, and others.[5] This edition of the report
also includes
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psnet.ahrq.gov/node/848107/psn-pdf
April 26, 2023 - This perspective includes the contribution of Dr. … Graber’s pioneering work on diagnostic error in 2005, which includes an identification of
systemic problems … Clinical decision making is a complex process that includes a variety of factors. … Clinician-centered misdiagnosis is only a part of overall diagnostic safety; the NASEM definition also
includes … guidance that scales to particular needs at the
level of individual practitioner whose scope of work includes
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psnet.ahrq.gov/node/863641/psn-pdf
February 28, 2024 - It includes a welcome
guide specific to the patients and family caregiver audience. … The website also includes new simulation-based training modules, which
can be used as tools to help … The core TeamSTEPPS materials on the website begin with an
Introduction, which includes an overview
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - Relevant documentation includes the case history, physical examination, signed consent form, and pre-anesthesia … unlike verification for medication or imaging orders, the standard protocol for verifying procedures includes … established in the 1980s, IR has been transitioning to a more clinically focused care delivery model that includes … Global Consensus Statement Defining Interventional Radiology, the clinical scope and practice of IR includes
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psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
September 01, 2017 - adequate data for further improvement—for instance, a daily monitoring report to the charge nurse that includes … Joint Commission recommends that each organization's: "process for effective hand off communication includes … Clinical content Includes everything on the data-information-knowledge continuum stored in the … Human–computer interface Enables unrelated entities to interact with the system and includes aspects
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psnet.ahrq.gov/node/33707/psn-pdf
February 01, 2011 - Research and QI projects
Course content includes
(but not limited to): systems
failure and medical … interventions in CQI
framework and designing
additional or new
interventions
Duration: 6 days
Course includes … Duration: 20 days
Course includes lectures
from national experts and
completion and reporting of … science, support
to attend meetings, and
bonuses for good
performance
Duration: 8 hours
Program includes
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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - , sepsis always involves activation of the host inflammatory response and, in more serious
states, includes … updated in 2013 by the Surviving Sepsis Campaign (SSC) and endorsed by multiple
medical societies, includes … timely manner.(4) Based on an
initial protocol performed by Rivers and colleagues (5), the bundle includes … UCSF Bundle Compliance and Mortality (Includes All Adult Inpatients and the Emergency
Department).
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
May 01, 2015 - initiated by an infection
Sepsis always involves activation of the host inflammatory response and often includes … treatment with the "resuscitation bundle"
The bundle, updated in the Surviving Sepsis Campaign in 2013, includes … www.ncbi.nlm.nih.gov/pubmed/23353941
12
Resuscitation Bundle
Based on a NEJM study published in 2001, the bundle includes