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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - A Tale of Two Falls
Citation Text:
Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.45_slideshow.ppt
January 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case January 2004
Crushing Chest Pain:
A Missed Opportunity
Source and Credits
This presentation is based on the Jan. 2004
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Mark Grabe…
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - Infusion Medication Error Reduction by Two-Person Verification: A Quality Improvement Initiative.
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - approach for identifying and defining factors that lead to misdiagnosis, such as the Systems Engineering Initiative
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psnet.ahrq.gov/node/848107/psn-pdf
April 26, 2023 - approach for identifying and defining factors that lead to misdiagnosis, such as the
Systems Engineering Initiative
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psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - as necessary to meet the regulatory or accreditation requirements but, rather, as a patient safety initiative
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psnet.ahrq.gov/node/33758/psn-pdf
December 01, 2013 - Let's say you weren't fundamentally interested
in IT-related safety issues, but you see a huge federal initiative
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psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
August 05, 2009 - 16, 2012
Improving departmental psychological safety through a medical school-wide initiative
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psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
June 07, 2023 - deficits of emergency airway management of tracheotomy and laryngectomy patients: a pilot patient safety initiative
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psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
July 01, 2017 - Shortcuts to Acetaminophen-induced Liver Failure
Citation Text:
Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google S…
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psnet.ahrq.gov/node/49780/psn-pdf
January 01, 2017 - The Missing Abscess: Radiology Reads in the Digital Era
January 1, 2017
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
Case Objectives
Identify the most common complication of hysterectomy.
Descr…
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psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something
May 01, 2019 - Liver Failure After Chemotherapy: Did We Forget Something?
Citation Text:
Lubel J. Liver Failure After Chemotherapy: Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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G…
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - Pathologic Mistake
Citation Text:
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
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psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization
Citation Text:
Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
April 24, 2018 - The Fluidity of Diagnostic "Wet Reads"
Citation Text:
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 …
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psnet.ahrq.gov/node/73650/psn-pdf
August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with
Recurrent Pneumothorax
August 25, 2021
Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent
Pneumothorax. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…
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psnet.ahrq.gov/node/44822/psn-pdf
September 04, 2016 - A cluster randomized trial of interventions to improve
work conditions and clinician burnout in primary care:
results from the Healthy Work Place (HWP) study.
September 4, 2016
Linzer M, Poplau S, Grossman E, et al. A Cluster Randomized Trial of Interventions to Improve Work
Conditions and Clinician Burnout in Pri…
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psnet.ahrq.gov/node/72525/psn-pdf
December 02, 2020 - Breast cancer treatment delays by socioeconomic and
health care access latent classes in Black and White
women.
December 2, 2020
Emerson MA, Golightly YM, Aiello AE, et al. Breast cancer treatment delays by socioeconomic and health
care access latent classes in Black and White women. Cancer. 2020;126(22):4957-4966…
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psnet.ahrq.gov/node/47935/psn-pdf
April 17, 2019 - Teaching patient safety in global health: lessons from the
Duke Global Health Patient Safety Fellowship.
April 17, 2019
Johnston BE, Lou-Meda R, Mendez S, et al. Teaching patient safety in global health: lessons from the
Duke Global Health Patient Safety Fellowship. BMJ Glob Health. 2019;4(1). doi:10.1136/bmjgh-201…
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psnet.ahrq.gov/node/34698/psn-pdf
January 04, 2017 - Using Health Care Failure Mode and Effect Analysis: the
VA National Center for Patient Safety's prospective risk
analysis system.
January 4, 2017
DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the VA
National Center for Patient Safety's prospective risk analysis s…