-
psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - The Wrong Shot: Error Disclosure
June 1, 2004
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
Case Objectives
Describe the rationale for disclosing harmful errors to patients.
Describe the specific information that patie…
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psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Transfer Troubles
June 1, 2012
Hains IM. Transfer Troubles. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfer-troubles
Case Objectives
Recognize that transfer of patients between hospitals is common.
Understand the frequency of errors and adverse events in the transfer of patients between hospitals.
…
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psnet.ahrq.gov/node/49642/psn-pdf
December 01, 2011 - Order Interrupted by Text: Multitasking Mishap
December 1, 2011
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
Case Objectives
State the prevalence of mobile devices among clinicians and their common health…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - PowerPoint Presentation
Spotlight
A Lot of Pain (Medications)
1
This presentation is based on the September 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…
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psnet.ahrq.gov/node/33707/psn-pdf
February 01, 2011 - The University of Texas System Clinical Safety and
Effectiveness Course
February 1, 2011
Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and
Effectiveness Course. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv…
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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx
Spotlight
Challenging Case of Multiple Suicide Attempts in a
Complex Patient with Psychiatric Comorbidities
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…
-
psnet.ahrq.gov/node/49606/psn-pdf
August 01, 2010 - Weighing In on Surgical Safety
August 1, 2010
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/weighing-surgical-safety
Case Objectives
Identify the comorbidites associated with obesity that place patients at higher risk for surgical
complications.
Un…
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psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
January 01, 2014 - drug-resistant pathogens are becoming increasingly prevalent in the community setting, and some data indicate … combination with targeted clinician education and use of explicit clinical decision support algorithms to indicate
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - , or decrements in quality of life.( 9 ) Data from the 2006 National Ambulatory Medical Care Survey indicate … Recent survey data from the National Center for Health Statistics indicate that approximately 17% of
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psnet.ahrq.gov/issue/designing-abstraction-instrument-lessons-efforts-validate-ahrq-patient-safety-indicators
January 13, 2010 - Commentary
Designing an abstraction instrument: lessons from efforts to validate the AHRQ Patient Safety Indicators.
Citation Text:
Utter GH, Borzecki A, Rosen AK, et al. Designing an abstraction instrument: lessons from efforts to validate the AHRQ patient safety indicators. Jt Comm J Q…
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psnet.ahrq.gov/node/847046/psn-pdf
April 05, 2023 - Indication documentation and indication-based
prescribing within electronic prescribing systems: a
systematic review and narrative synthesis.
April 5, 2023
Feather C, Appelbaum N, Darzi A, et al. Indication documentation and indication-based prescribing within
electronic prescribing systems: a systematic review an…
-
psnet.ahrq.gov/node/860380/psn-pdf
January 10, 2024 - Validity of 16 AHRQ Patient Safety Indicators to identify
in-hospital complications: a medical record review across
nine Swiss hospitals.
January 10, 2024
Havranek MM, Rüter F, Bilger S, et al. Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital
complications: a medical record review across nine …
-
psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - the vast majority of hospitals whose average rates of deaths in low-mortality DRGs do not actually
indicate
-
psnet.ahrq.gov/node/33800/psn-pdf
January 01, 2015 - , and the authors assumed lower
implementation costs than recent reports from health systems would indicate
-
psnet.ahrq.gov/node/74022/psn-pdf
March 01, 2021 - substances,
such as consulting prescription drug monitoring programs to look for patterns that might indicate
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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - Patient Safety Indicators
April 26, 2023
Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/patient-safety-indicators
Background
Over the past 25 years, policymakers and providers, payers, and purchasers of health care have
increasingly focused attention on pati…
-
psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - the vast majority of hospitals whose average rates of deaths in low-mortality DRGs do not actually indicate
-
psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
June 01, 2015 - that many of them have "critical illness–related corticosteroid insufficiency," and in vitro studies indicate … stercoralis , for example, responds to treatment with thiabendazole and ivermectin, and various studies indicate
-
psnet.ahrq.gov/node/33675/psn-pdf
October 01, 2008 - and Medicaid Services (CMS) mandate to submit an
additional field for each secondary diagnosis to indicate
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
October 01, 2011 - immobility with the benefits gained from a program of therapeutic exercise
Identify criteria that indicate