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psnet.ahrq.gov/node/40013/psn-pdf
July 24, 2011 - Patient participation in surgical site marking: can this be
an additional tool to help avoid wrong-site surgery?
July 24, 2011
Bergal LM, Schwarzkopf R, Walsh M, et al. Patient participation in surgical site marking: can this be an
additional tool to help avoid wrong-site surgery? J Patient Saf. 2010;6(4):221-5.
h…
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psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
August 01, 2007 - information about external quality and safety demands, an overview of the organization's quality and safety initiatives … The "Boards on Board" piece was a departure from the other types of initiatives.
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psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
December 01, 2014 - Phase 1: Co-development and program design (2009–2011)
Unlike other patient safety initiatives to date … APPS focused on influencing national patient safety initiatives by highlighting what had been learned
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psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
August 01, 2007 - The "Boards on Board" piece was a departure from the other types of initiatives. … information about external quality and safety demands, an overview of the organization's quality and safety initiatives
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psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - communication channels that make it easier to identify our members' needs and obtain feedback on our initiatives … The HITECH Act and other initiatives dealing with IT try to simplify providers' lives by automating things
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
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February 9, 2021
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psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
December 02, 2020 - SPOTLIGHT CASE
The Lost Start Date: an Unknown Risk of E-prescribing
Citation Text:
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - SPOTLIGHT CASE
Crushing Chest Pain: A Missed Opportunity
Citation Text:
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google …
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psnet.ahrq.gov/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
“This is the wrong patient’s blood!”:
Evaluating a Near-Miss Wrong
Transfusion Event
Source and Credits
• This presentation is based on the January 2020 AHRQ WebM&M
Spotlight Case
• Commentary by: Sarah Barnhard MD
o Medical Director of Transfusion Services at UC-Davis Health
o Editors in …
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - Proposed System Changes Initiatives to reduce expenses in hospitals have caused rehabilitation departments
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding
September 1, 2017
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
Case Objectives
Describe risk factors for poor outcome in patients w…
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psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
June 01, 2016 - A Seasonal Care Transition Failure
Citation Text:
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - Crossed Coverage
Citation Text:
Kayser SR. Crossed Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/node/49828/psn-pdf
May 01, 2018 - Issues and initiatives in the testing
process in primary care physician offices.
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psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
July 10, 2024 - Interview
In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives
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psnet.ahrq.gov/issue/emergency-medical-services-responders-perceptions-effect-stress-and-anxiety-patient-safety
January 22, 2016 - Study
Emergency medical services responders' perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study.
Citation Text:
Guise J-M, Hansen M, O'Brien K, et al. Emergency medical services responders' perceptions …
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psnet.ahrq.gov/issue/experience-hospital-initiated-medication-changes-older-people-multimorbidity-multicentre
August 18, 2021 - Study
Experience of hospital-initiated medication changes in older people with multimorbidity: a multicentre mixed-methods study embedded in the OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people (OPERAM) trial.
Citation Text:
Thevelin S, Pétein C, Me…
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psnet.ahrq.gov/issue/well-defined-pediatric-icu-active-surveillance-using-nonmedical-personnel-capture-less
July 13, 2010 - Study
The well-defined pediatric ICU: active surveillance using nonmedical personnel to capture less serious safety events.
Citation Text:
White WA, Kennedy K, Belgum HS, et al. The Well-Defined Pediatric ICU: Active Surveillance Using Nonmedical Personnel to Capture Less Serious Safety …
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psnet.ahrq.gov/issue/performance-trigger-tool-detecting-drug-related-hospital-admissions-older-people-analysis
December 21, 2022 - Study
Performance of a trigger tool for detecting drug-related hospital admissions in older people: analysis from the OPERAM trial.
Citation Text:
Zerah L, Henrard S, Thevelin S, et al. Performance of a trigger tool for detecting drug-related hospital admissions in older people: analysis…
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psnet.ahrq.gov/node/49719/psn-pdf
September 01, 2014 - Quality and safety in pediatric anesthesia: how can
guidelines, checklists, and initiatives improve