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psnet.ahrq.gov/innovations
February 26, 2025 - Inpatient Suicide
(1)
Wrong Patient
(1)
Patient Safety Indicators
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psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
January 01, 2024 - EHR systems should incorporate easily seen indicators and notifications when hemolysis is detected.
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psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - Missed Opportunities for Suicide Risk Assessment
November 27, 2019
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
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psnet.ahrq.gov/node/861738/psn-pdf
January 31, 2024 - A Laceration that Needed a Proper Exam, Not an X-Ray
January 31, 2024
Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
Disclosure of Relevant Financial Relationships: As a provider accredited by t…
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psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
January 01, 2024 - Spotlight
Spotlight
Laceration that Needed a Proper Exam, Not an X-Ray
Source and Credits
• This presentation is based on the January 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Jazmin A. Wander, MD and David K. Barnes, MD,
F…
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
June 28, 2023
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue
Necrosis and Cuff Rupture. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…
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psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc
June 12, 2019 - In Conversation With… David Urbach, MD, MSc
April 1, 2015
Citation Text:
In Conversation With… David Urbach, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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…
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psnet.ahrq.gov/node/49723/psn-pdf
January 01, 2015 - Monitoring Fetal Health
January 1, 2015
Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/monitoring-fetal-health
Case Objectives
Define fetal heart rate monitoring.
Describe the current state of evidence regarding fetal heart rate monitoring.
List the known …
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation
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August 30, 2023
View more articles from the…
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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/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx
Spotlight
The Dose Makes the Poison: Medication Error During
Procedural Sedation in the Pediatric Emergency
Department
Source and Credits
• This presentation is based on the April 2023 AH…
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - SPOTLIGHT CASE
The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.
Citation Text:
Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.. PSNet [internet]. Rockv…
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psnet.ahrq.gov/issue/influence-opioid-prescription-policy-overdoses-and-related-adverse-effects-primary-care
March 24, 2021 - Study
Influence of opioid prescription policy on overdoses and related adverse effects in a primary care population.
Citation Text:
Harder VS, Plante TB, Koh I, et al. Influence of opioid prescription policy on overdoses and related adverse effects in a primary care population. J Gen Int…
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psnet.ahrq.gov/innovation/clinician-collaboration-improve-clinical-decision-support-clickbusters-initiative
October 21, 2020 - EMERGING INNOVATIONS
Clinician collaboration to improve clinical decision support: the Clickbusters initiative.
Citation Text:
Clinician collaboration to improve clinical decision support: the Clickbusters initiative. Mc Coy AB, Russo EM, Johnson KB, et al. Clinician collaboration to improve clini…
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psnet.ahrq.gov/innovation/reducing-hospital-harm-establishing-command-centre-foster-situational-awareness
June 29, 2022 - EMERGING INNOVATIONS
Reducing hospital harm: establishing a command centre to foster situational awareness.
Citation Text:
Collins B. Reducing hospital harm: establishing a command centre to foster situational awareness. Healthc Q. 2022;25(2):75-81. doi:10.12927/hcq.2022.26885.
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…
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psnet.ahrq.gov/issue/evaluation-association-between-hospital-survey-patient-safety-culture-hsops-measures-and
December 21, 2017 - Study
Evaluation of the association between Hospital Survey on Patient Safety Culture (HSOPS) measures and catheter-associated infections: results of two national collaboratives.
Citation Text:
Meddings J, Reichert H, Greene T, et al. Evaluation of the association between Hospital Survey…
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psnet.ahrq.gov/issue/using-medication-containers-during-pharmacist-transitional-care-visits-and-impact-medication
March 08, 2023 - Study
Using medication containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital readmission risk.
Citation Text:
Herges JR, Garrison GM, Mara KC, et al. Using medication containers during pharmacist transitional care visits and …
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psnet.ahrq.gov/issue/characteristics-initial-prescription-episodes-and-likelihood-long-term-opioid-use-united
April 24, 2018 - Study
Classic
Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015.
Citation Text:
Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - …
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psnet.ahrq.gov/issue/risk-wrong-patient-orders-among-multiple-vs-singleton-births-neonatal-intensive-care-units-2
December 21, 2017 - Study
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.
Citation Text:
Adelman JS, Applebaum JR, Southern WN, et al. Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Int…