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psnet.ahrq.gov/node/860050/psn-pdf
January 04, 2024 - AHT occurs from
direct impact to the head, shaking, or a combination of both, and can lead to serious
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psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
September 07, 2019 - phases, the use of data-driven goals to guide design of deprescribing interventions will ultimately lead
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - prepared to deliver strategies for helping the patient
population with their psychosocial challenges that lead
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - atypical smooth muscle-like cells called LAM cells that carry mutations in the TSC1 or TSC2 genes that lead
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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - Its absence can quickly lead to misunderstandings, failed directives, and disruptions in workflow that
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - We can only hope that this will soon lead to more effective handoffs in anesthesia.
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psnet.ahrq.gov/web-mm/undetected-foreign-object
April 24, 2018 - safety suggest improving team communication, flattening hierarchy, and teaching and enhancing teamwork lead
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psnet.ahrq.gov/periodic-issue/periodic-issue-376
February 01, 2023 - Delays in diagnosis and treatment can lead to poor outcomes.
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psnet.ahrq.gov/node/73300/psn-pdf
July 01, 2022 - Implemented
2005-01-01
Problem Addressed
Recently discharged patients often suffer complications that lead
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - waiting room
– Performance and frequency of patient reassessment
23
Triage
• ESI framework may lead
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psnet.ahrq.gov/node/49840/psn-pdf
September 01, 2018 - multifaceted approach is needed to address each of these
factors and ensure that systems issues do not lead
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psnet.ahrq.gov/node/867206/psn-pdf
December 18, 2024 - vomiting and dizziness.42
At the same time, concern about missing a stroke in patients with dizziness can lead … , would lead
most radiologists to carefully scrutinize the structures fed by the posterior circulation
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psnet.ahrq.gov/issue/how-i-minimize-mistransfusion-risk-my-hospital
July 22, 2015 - Commentary
How I minimize mistransfusion risk in my hospital.
Citation Text:
Aubuchon JP. How I minimize mistransfusion risk in my hospital. Transfusion (Paris). 2006;46(7):1085-9.
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psnet.ahrq.gov/issue/piece-my-mind-mistakes
March 19, 2008 - Commentary
A piece of my mind. Mistakes.
Citation Text:
Lesnewski R. A piece of my mind. Mistakes. JAMA. 2006;296(11):1327-8.
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psnet.ahrq.gov/issue/when-does-quality-improvement-count-research-human-subject-protection-and-theories-knowledge
July 10, 2019 - Commentary
When does quality improvement count as research? Human subject protection and theories of knowledge.
Citation Text:
Lynn J. When does quality improvement count as research? Human subject protection and theories of knowledge. Qual Saf Health Care. 2004;13(1):67-70.
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psnet.ahrq.gov/issue/diagnostic-errors-medicine-case-neglect
July 15, 2015 - Study
Diagnostic errors in medicine: a case of neglect.
Citation Text:
Graber ML. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2005;31(2):106-13.
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psnet.ahrq.gov/issue/next-patient-safety
September 11, 2019 - Audiovisual Presentation
Up Next for Patient Safety.
Citation Text:
National Patient Safety Board. 2021-2023.
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June 9, 2023
…
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psnet.ahrq.gov/node/49397/psn-pdf
May 01, 2003 - The Dropped Lung
May 1, 2003
Heffner JR. The Dropped Lung. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dropped-lung
The Case
A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been
hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
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psnet.ahrq.gov/issue/oral-chemotherapy-not-just-ordinary-pill
May 05, 2018 - Newspaper/Magazine Article
Oral chemotherapy: not just an ordinary pill.
Citation Text:
Oral chemotherapy: not just an ordinary pill. ISMP Canada. SafeMedicineUse. August 19, 2015;6:1-2.
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psnet.ahrq.gov/issue/adverse-events-cough-and-cold-medications-after-market-withdrawal-products-labeled-infants
August 02, 2015 - Study
Adverse events from cough and cold medications after a market withdrawal of products labeled for infants.
Citation Text:
Shehab N, Schaefer MK, Kegler SR, et al. Adverse events from cough and cold medications after a market withdrawal of products labeled for infants. Pediatrics. 20…