-
psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - experience and preference, guided by how tracheostomy supplies are managed and made
available in an institution
-
psnet.ahrq.gov/node/33822/psn-pdf
January 01, 2017 - was recently asked to come in by an outside board member to a very famous, very large medical care
institution
-
psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - Our institution has designed online education
modules for continuing medical education (CME) that coincide
-
psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - Risk factors for and occurrence of postoperative cervical hematoma after thyroid surgery: A single-institution
-
psnet.ahrq.gov/node/49861/psn-pdf
May 01, 2019 - unknown, the decision to perform CDT is
often a challenging one to make and is frequently clinician- and institution-dependent
-
psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - evidence to support the use of one protocol over another, so the details can be tailored to a specific institution
-
psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - At our
institution, we require a successive check, with the interventional radiologist reviewing all
-
psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - For example, the physician-patient mentioned above tried to engage senior leadership in focusing the institution
-
psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - an indicator like death in a low-mortality DRG as a screening test, that, when positive, leads an institution
-
psnet.ahrq.gov/node/33662/psn-pdf
January 01, 2008 - In Conversation with…Jennifer Daley, MD
January 1, 2008
In Conversation with…Jennifer Daley, MD. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
Editor's note: Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the
organization for …
-
psnet.ahrq.gov/node/50769/psn-pdf
February 15, 2017 - Cultural Competence and Patient Safety
December 27, 2019
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
Background
Culture can be defined as the “personal identification, language, thoughts, co…
-
psnet.ahrq.gov/node/33717/psn-pdf
September 01, 2011 - Incident Reporting: More Attention to the Safety Action
Feedback Loop, Please
September 1, 2011
Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet
[internet]. 2011.
https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
…
-
psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
-
psnet.ahrq.gov/sites/default/files/2020-04/spotlight-slides-wright-schiff.pdf
January 01, 2020 - Spotlight
The Lost Start Date, an Unknown
Risk of E-prescribing
Source and Credits
• This presentation is based on the October 2019
AHRQ WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Adam Wright, PhD, and Gordon
Schiff, MD
○ Editor, AHRQ…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
October 01, 2009 - Spotlight Case
Spotlight Case
Difficult Encounters:
A CMO and CNO Respond
Source and Credits
This presentation is based on the October 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Ernie Ring, MD; Jane Hirsch, RN, MS
UCSF Medical Cen…
-
psnet.ahrq.gov/node/46098/psn-pdf
July 24, 2017 - Prospective evaluation of a multifaceted intervention to
improve outcomes in intensive care: the Promoting
Respect and Ongoing Safety through Patient Engagement
Communication and Technology study.
July 24, 2017
Dykes PC, Rozenblum R, Dalal A, et al. Prospective Evaluation of a Multifaceted Intervention to Improve
…
-
psnet.ahrq.gov/node/42067/psn-pdf
March 18, 2013 - Methodological variations and their effects on reported
medication administration error rates.
March 18, 2013
McLeod MC, Barber N, Franklin BD. Methodological variations and their effects on reported medication
administration error rates. BMJ Qual Saf. 2013;22(4):278-89. doi:10.1136/bmjqs-2012-001330.
https://psne…
-
psnet.ahrq.gov/node/42342/psn-pdf
December 31, 2014 - The safety of electronic prescribing: manifestations,
mechanisms, and rates of system-related errors
associated with two commercial systems in hospitals.
December 31, 2014
Westbrook JI, Baysari M, Li L, et al. The safety of electronic prescribing: manifestations, mechanisms, and
rates of system-related errors asso…
-
psnet.ahrq.gov/node/38674/psn-pdf
February 17, 2011 - Cost implications of reduced work hours and workloads
for resident physicians.
February 17, 2011
Nuckols TK, Bhattacharya J, Wolman DM, et al. Cost implications of reduced work hours and workloads for
resident physicians. N Engl J Med. 2009;360(21):2202-15. doi:10.1056/NEJMsa0810251.
https://psnet.ahrq.gov/issue/c…
-
psnet.ahrq.gov/node/43067/psn-pdf
November 23, 2014 - Characterization of adverse events detected in a large
health care delivery system using an enhanced Global
Trigger Tool over a five-year interval.
November 23, 2014
Kennerly DA, Kudyakov R, da Graca B, et al. Characterization of adverse events detected in a large health
care delivery system using an enhanced glob…