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psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - Root Cause Analysis Gone Wrong
May 1, 2018
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
The Case
A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney
transplant. A suitabl…
-
psnet.ahrq.gov/node/33769/psn-pdf
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things
Changed?
June 1, 2014
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
Perspective
In 1981, a cancer patient named Paula Carroll founded…
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hcup-us.ahrq.gov/db/nation/nis/OverviewofSeveritySystems.pdf
December 09, 2005 - Overview of Severity Measurement Systems
Overview of Disease Severity Measures
Disseminated with the
Nationwide Inpatient Sample (NIS)
and
Kids’ Inpatient Database (KID)
Executive Summary
Adding severity adjustment measures to the HCUP Nationwide Inpatient Sample (NIS)
and Kids’ Inpatient Database (…
-
psnet.ahrq.gov/node/33806/psn-pdf
April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of
Pediatrics a…
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hcup-us.ahrq.gov/db/nation/nis/severity_overview.jsp
September 01, 2025 - Overview of Disease Severity Measures Disseminated with the Nationwide Inpatient Sample (NIS) and Kids' Inpatient Database (KID)
An official website of the Department of Health & Human Services
Sea…
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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - Good Catch in the Operating Room
Citation Text:
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
-
psnet.ahrq.gov/node/49482/psn-pdf
May 01, 2005 - Pregnant With Danger
May 1, 2005
Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pregnant-danger
The Case
A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of
the night complaining of left leg pain. She also had so…
-
hcup-us.ahrq.gov/reports/factsandfigures/facts_figures_2005.jsp
January 01, 2005 - 0.9
4.2
4.3
4.1
PTCA (percutaneous transluminal coronary angioplasty, procedure involving … 1.3
3.5
4.0
3.9
PTCA (percutaneous transluminal coronary angioplasty, procedure involving … The number of hospital stays involving a transfusion more than doubled from 1997 to 2005 for each of … supply to the heart muscle)
45 PTCA (percutaneous transluminal coronary angioplasty, procedure involving
-
psnet.ahrq.gov/node/837784/psn-pdf
August 05, 2022 - think there’s a lot that we can do to promote patient safety in health
app design and development: involving
-
www.ahrq.gov/sites/default/files/wysiwyg/topics/managing-interruptions-improve-diagnostic-decisionmaking.pdf
December 29, 2022 - simple tasks, they often lead to
errors on harder and more complex tasks/environments (e.g.,
tasks involving
-
www.uspreventiveservicestaskforce.org/uspstf/recommendation/syphilis-infection-in-nonpregnant-adults-and-adolescents-june-2016
June 07, 2016 - Screening for syphilis infection is a 2-step process involving an initial nontreponemal test (Venereal
-
psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
February 01, 2014 - reports, assuring that during shift changes it is not simply one nurse talking with another, but also involving
-
psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
December 07, 2020 - Between 1999 and 2018, more than 232,000 individuals in the United States died because of an overdose involving
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/alarm-fatigue-1.pdf
March 01, 2020 - of safety in a unit or hospital can be difficult, and this PSP includes a variety of
interventions involving … For example, Vockley notes that after two sentinel events involving
alarm signals at the studied hospital
-
www.ahrq.gov/sites/default/files/2024-07/ebeling-report.pdf
January 01, 2024 - Final Progress Report: EMR Planning To Improve North Iowa Healthcare
AHRQ Grant Final Progress Report
Title of Project: EMR Planning to Improve North Iowa Healthcare
Principal Investigator and Team (Steering Committee) Members:
• Toni Ebeling (Principal Investigator), RN, MSN, formerly, Chief Executive Officer, …
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
January 01, 2004 - Diagnostic Failure: A Cognitive and Affective Approach
241
Diagnostic Failure: A Cognitive
and Affective Approach
Pat Croskerry
Abstract
Diagnosis is the foundation of medicine. Effective treatment cannot begin until an
accurate diagnosis has been made. Diagnostic reasoning is a critical aspect of
clinic…
-
www.uspreventiveservicestaskforce.org/home/getfilebytoken/YFZy6kszQPq5tNGdZC25XC
July 26, 2016 - Screening for Skin Cancer: U.S. Preventive Services Task Force Recommendation Statement
Copyright 2016 American Medical Association. All rights reserved.
Screening for Skin Cancer
US Preventive Services Task Force
Recommendation Statement
US Preventive Services Task Force
T he US Preventive Services Task Force (USP…
-
effectivehealthcare.ahrq.gov/sites/default/files/developmental-delays-horizon-scan-high-impact-1406.pdf
June 01, 2014 - #06 Developmental Delays ADHD, and Autism
AHRQ Healthcare Horizon Scanning System – Potential
High-Impact Interventions Report
Priority Area 06: Developmental Delays, ADHD,
and Autism
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaithe…
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/disposition-of-comments-cer-192-anxiety-in-children.pdf
August 31, 2017 - Comparative Effectiveness Review Disposition of Comments Report: Anxiety in Children
Source: https://effectivehealthcare.ahrq.gov/topics/anxiety-children/research-2017/
Published Online: August 31, 2017
Comparative Effectiveness Review Disposition of Comments Report
Research Review Title: Anxiety in Children
D…
-
digital.ahrq.gov/sites/default/files/docs/citation/r21hs022670-patel-final-report-2019.pdf
January 01, 2019 - characterize the nature of activities on the EHR during clinical
workflow, conducted over a two-month period, involving