-
psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - Getting a Good Report Card: Unintended Consequences
of the Public Reporting of Hospital Quality
November 1, 2006
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of
Hospital Quality. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…
-
psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing
October 30, 2019
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
Case Objectives
List the most common errors associated with computerized…
-
psnet.ahrq.gov/node/49651/psn-pdf
May 01, 2012 - The Perils of Cross Coverage
May 1, 2012
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/perils-cross-coverage
Case Objectives
Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and
care transitions.
Describe ed…
-
psnet.ahrq.gov/node/49811/psn-pdf
November 01, 2017 - Delayed Diagnosis of Endocrinologic Emergencies
November 1, 2017
Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
The Cases
Case #1:
A 47-year-old man with a history of hyperthyroidism and h…
-
psnet.ahrq.gov/web-mm/slippery-slide-life
January 21, 2017 - Slippery Slide Into Life
Citation Text:
Halamek LP. Slippery Slide Into Life. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
-
psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx
Spotlight
Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm…
-
psnet.ahrq.gov/node/60865/psn-pdf
August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-
BC-FACHE
August 31, 2020
In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
Editor’s Note: Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is …
-
psnet.ahrq.gov/node/49684/psn-pdf
May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical
Error
May 1, 2013
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet].
2013.
https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
Case Objectives
Appreciate that chemotherapy a…
-
psnet.ahrq.gov/node/49733/psn-pdf
May 01, 2015 - Transitions in Adolescent Medicine
May 1, 2015
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
The Case
A 21-year-old woman with a history of Marfan syndrome complicated by aortic root dilation presented to the
emer…
-
psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - SPOTLIGHT CASE
Bad Writing, Wrong Medication
Citation Text:
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
-
psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - Annual Perspective
Patient Safety in the Ambulatory Care Setting
August 5, 2022
View more articles from the same authors.
Citation Text:
Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. Rockville (MD): …
-
psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - SPOTLIGHT CASE
Near Miss with Bedside Medications
Citation Text:
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTeX End…
-
psnet.ahrq.gov/issue/errors-during-resuscitation-impact-perceived-authority-delivery-care
April 03, 2019 - Study
Errors during resuscitation: the impact of perceived authority on delivery of care.
Citation Text:
Delaloye NJ, Tobler K, OʼNeill T, et al. Errors during resuscitation: the impact of perceived authority on delivery of care. J Patient Saf. 2020;16(1). doi:10.1097/pts.000000000000035…
-
psnet.ahrq.gov/issue/perceptions-impact-large-scale-collaborative-improvement-programme-experience-uk-safer
February 01, 2011 - Study
Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK Safer Patients Initiative.
Citation Text:
Benn J, Burnett S, Parand A, et al. Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK …
-
psnet.ahrq.gov/issue/reducing-catheter-associated-bloodstream-infections-pediatric-intensive-care-unit-business
November 23, 2016 - Study
Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement.
Citation Text:
Nowak JE, Brilli RJ, Lake MR, et al. Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: Business …
-
psnet.ahrq.gov/issue/expanding-role-antimicrobial-stewardship-programs-hospitals-united-states-lessons-learned
March 04, 2015 - Study
The expanding role of antimicrobial stewardship programs in hospitals in the United States: lessons learned from a multisite qualitative study.
Citation Text:
Kapadia SN, Abramson EL, Carter EJ, et al. The Expanding Role of Antimicrobial Stewardship Programs in Hospitals in the Uni…
-
psnet.ahrq.gov/issue/impact-80-hour-resident-workweek-surgical-residents-and-attending-surgeons
January 04, 2010 - Study
The impact of the 80-hour resident workweek on surgical residents and attending surgeons.
Citation Text:
Hutter MM, Kellogg KC, Ferguson CM, et al. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg. 2006;243(6):864-71; discussion 8…
-
psnet.ahrq.gov/issue/performance-trigger-tool-identifying-adverse-events-oncology
May 23, 2018 - Study
Performance of a trigger tool for identifying adverse events in oncology.
Citation Text:
Lipitz-Snyderman A, Classen D, Pfister D, et al. Performance of a Trigger Tool for Identifying Adverse Events in Oncology. J Oncol Pract. 2017;13(3). doi:10.1200/jop.2016.016634.
Copy Citatio…
-
psnet.ahrq.gov/issue/errare-humanum-est-frequency-laterality-errors-radiology-reports
September 13, 2023 - Study
Errare humanum est: frequency of laterality errors in radiology reports.
Citation Text:
Sangwaiya MJ, Saini S, Blake MA, et al. Errare humanum est: frequency of laterality errors in radiology reports. AJR Am J Roentgenol. 2009;192(5):W239-44. doi:10.2214/AJR.08.1778.
Copy Citatio…
-
psnet.ahrq.gov/issue/universal-surveillance-methicillin-resistant-staphylococcus-aureus-3-affiliated-hospitals
December 23, 2008 - Study
Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals.
Citation Text:
Robicsek A, Beaumont JL, Paule SM, et al. Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. Ann Intern Med. 2008;148(6)…