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psnet.ahrq.gov/node/49861/psn-pdf
May 01, 2019 - Updates in the Management of High-Risk Pulmonary
Embolism
May 1, 2019
Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
Case Objectives
Review common risk factors, typical present…
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psnet.ahrq.gov/node/49765/psn-pdf
August 21, 2016 - Cognitive Overload in the ICU
August 21, 2016
Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/cognitive-overload-icu
Case Objectives
Identify the role of cognitive overload—especially interruptions—in compromising quality of care and
patient safety.
List…
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
Citation Text:
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - All in the History
March 21, 2009
Fee C. All in the History. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/all-history
Case Objectives
Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it
does not apply to transfers to emergency departments from non-acute care faci…
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psnet.ahrq.gov/node/35460/psn-pdf
June 17, 2014 - Medication safety issue brief. Look-alike, sound-alike
drugs.
June 17, 2014
Association AH, Pharmacists AS of H-S, Networks H & H. Medication safety issue brief, look-alike, sound-
alike drugs. Hospitals and Health Networks. October 2005;79(10):57-58.
https://psnet.ahrq.gov/issue/medication-safety-issue-brief-look…
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psnet.ahrq.gov/node/39049/psn-pdf
January 16, 2010 - Approaching the evidence basis for aviation-derived
teamwork training in medicine.
January 16, 2010
Zeltser M, Nash DB. Approaching the evidence basis for aviation-derived teamwork training in medicine.
Am J Med Qual. 2010;25(1):13-23. doi:10.1177/1062860609345664.
https://psnet.ahrq.gov/issue/approaching-evidence…
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psnet.ahrq.gov/node/34603/psn-pdf
September 29, 2017 - Disclosure of unanticipated events: creating an effective
patient communication policy (part 2 of 3).
September 29, 2017
American Society of Healthcare Risk Management; ASHRM
https://psnet.ahrq.gov/issue/disclosure-unanticipated-events-creating-effective-patient-communication-
policy-part-2-3
The process for craf…
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psnet.ahrq.gov/node/40773/psn-pdf
January 04, 2012 - Complementary telephone strategies to improve
postdischarge communication.
January 4, 2012
Rennke S, Kesh S, Neeman N, et al. Complementary telephone strategies to improve postdischarge
communication. Am J Med. 2012;125(1):28-30. doi:10.1016/j.amjmed.2011.05.011.
https://psnet.ahrq.gov/issue/complementary-telephon…
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psnet.ahrq.gov/node/37762/psn-pdf
May 14, 2008 - commentary describes the strategy used at one hospital to enhance an existing rapid response team
initiative
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psnet.ahrq.gov/node/40698/psn-pdf
August 17, 2011 - an ambulatory surgery safety improvement program and describes its background,
goals, and checklist initiative
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psnet.ahrq.gov/node/40669/psn-pdf
August 27, 2013 - https://psnet.ahrq.gov/issue/state-action-avoidable-rehospitalizations
This Web site supports an initiative
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psnet.ahrq.gov/node/43268/psn-pdf
June 11, 2014 - interventions-improve-safe-and-effective-medicines-use-consumers-overview-systematic-reviews
https://psnet.ahrq.gov/issue/protect-initiative-advancing-childrens-medication-safety
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psnet.ahrq.gov/node/35988/psn-pdf
May 04, 2015 - eliminating-serious-preventable-and-costly-medical-errors-never-events
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative
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psnet.ahrq.gov/node/40501/psn-pdf
June 01, 2011 - Presenting a hypothetical example of organizational and individual resistance to a surgical checklist
initiative
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psnet.ahrq.gov/node/36607/psn-pdf
February 28, 2015 - consumer-guide-adverse-health-events
This report provides background on the Minnesota Never Events reporting initiative
-
psnet.ahrq.gov/node/41882/psn-pdf
November 28, 2012 - what-nhs-safety-thermometer
This commentary describes the design and initial test of a large-scale initiative
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psnet.ahrq.gov/node/38187/psn-pdf
October 29, 2008 - importance-simulation-preventing-hand-mistakes
This article discusses an AHRQ-funded communication survey initiative
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psnet.ahrq.gov/node/36036/psn-pdf
April 29, 2018 - /rapid-response-team-activation-patients-can-mitigate-errors
This article discusses one hospital's initiative
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psnet.ahrq.gov/node/38380/psn-pdf
February 04, 2009 - towards-international-classification-patient-safety
This set of articles focuses on the World Alliance for Patient Safety initiative
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psnet.ahrq.gov/node/41581/psn-pdf
August 08, 2012 - how-guides-improving-transitions-hospital-reduce-avoidable-rehospitalizations
This series, developed in conjunction with the STAAR initiative