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psnet.ahrq.gov/issue/management-difficult-airway-closed-claims-analysis
July 13, 2010 - administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated
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psnet.ahrq.gov/node/33642/psn-pdf
November 01, 2006 - DN: What we need is systems thinking, first of all, and second, integrated displays that capture a large … But each display now has this wonderfully integrated picture—it is not only easy to understand, but it … Second, the equipment that is well done is still not well
integrated through a system analysis.
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psnet.ahrq.gov/node/33753/psn-pdf
August 22, 2013 - improvements in safety culture and decreased infection rates.(8) We have
unpublished data from large integrated … All the above components have been integrated into the TEM
(Team-based Engagement Model) that we developed
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psnet.ahrq.gov/issue/high-fidelity-simulation-and-safety-integrative-review
September 09, 2015 - Review
High-fidelity simulation and safety: an integrative review.
Citation Text:
Shearer JE. High-fidelity simulation and safety: an integrative review. J Nurs Edu. 2013;52(1):39-45. doi:10.3928/01484834-20121121-01.
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DOI Google Scholar PubMed BibTeX…
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psnet.ahrq.gov/issue/integrating-cusp-and-trip-improve-patient-safety
June 16, 2011 - Commentary
Integrating CUSP and TRIP to improve patient safety.
Citation Text:
Romig M, Goeschel CA, Pronovost P, et al. Integrating CUSP and TRIP to improve patient safety. Hosp Pract (1995). 2010;38(4):114-21. doi:10.3810/hp.2010.11.348.
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DOI Google…
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psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
November 01, 2023 - Inadvertent Use of More Potent Acid Leads to Burn
Citation Text:
Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Google Scholar B…
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psnet.ahrq.gov/web-mm/mark-my-limb
February 10, 2015 - Mark My Limb
Citation Text:
Jacott WE, O'Leary D. Mark My Limb. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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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/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
July 01, 2011 - Spotlight Case July 2008
Spotlight Case
Watch the Warfarin!
1
2
Source and Credits
This presentation is based on the July 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Raman Khanna, MD, and Margaret Fang, MD, MPH; University of California, Sa…
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psnet.ahrq.gov/node/73303/psn-pdf
May 26, 2021 - Safety Culture in EMS
May 26, 2021
Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/safety-culture-ems
Defining a Just Culture
A Just Culture is one that supports transparent and honest error reporting with the goal of fostering an
environmen…
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psnet.ahrq.gov/node/49460/psn-pdf
September 01, 2004 - Security Lapse
September 1, 2004
Mason D. Security Lapse. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/security-lapse
The Case
A medical student learned that the hospital's radiology image library was accessible throughout the
university's computer system, meaning that patient x-rays could be viewed in d…
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psnet.ahrq.gov/node/33713/psn-pdf
June 01, 2011 - The Safety of Medical Devices
June 1, 2011
Nemeth CP. The Safety of Medical Devices. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/safety-medical-devices
Perspective
Edward Tenner is right. Technology does have reverberations, including unintended consequences, or
"revenge effects."(1) While such dra…
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psnet.ahrq.gov/node/49524/psn-pdf
November 01, 2006 - Secured But Not Always Safe
November 1, 2006
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/secured-not-always-safe
The Case
An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative
osteoarthritis. She received spinal …
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psnet.ahrq.gov/node/50615/psn-pdf
October 30, 2019 - Misidentifying the Unidentified – John Doe and the EHR
October 30, 2019
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
The Case
Two male patients of similar age arrived at the same …
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psnet.ahrq.gov/issue/concept-analysis-situational-awareness-nursing
August 12, 2015 - November 4, 2020
Implementation of a high-reliability organization framework in a large integrated
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psnet.ahrq.gov/issue/using-automated-risk-assessment-report-identify-patients-risk-clinical-deterioration
February 15, 2017 - Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated
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psnet.ahrq.gov/issue/increasing-adoption-computerized-provider-order-entry-and-persistent-regional-disparities-us
May 16, 2012 - Significant reduction in preanalytical errors for nonphlebotomy blood draws after implementation of a novel integrated
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psnet.ahrq.gov/issue/time-trends-pulmonary-embolism-united-states-evidence-overdiagnosis
February 18, 2011 - November 16, 2022
The effectiveness of integrated health information technologies across
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psnet.ahrq.gov/issue/meaningful-uses-benefits-and-burdens-us-family-physicians
November 30, 2011 - October 21, 2015
Primary care medication safety surveillance with integrated primary
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psnet.ahrq.gov/issue/medication-prescribing-errors-teaching-hospital
December 23, 2008 - application and associated services to support interdisciplinary medication reconciliation efforts at an integrated
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psnet.ahrq.gov/issue/safety-incidents-family-medicine
December 11, 2013 - March 28, 2011
The development and evaluation of an integrated electronic prescribing