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  1. Rapid Response Systems | PSNet

    psnet.ahrq.gov/curated-library/rapid-response-systems
    September 15, 2024 - More Spotlight Case Delay in Appropriate Diagnosis and Treatment Leading … Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism David Barnes

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46197/psn-pdf
    September 24, 2017 - A past PSNet interview featured Dave deBronkart, a leading advocate for engaging patients in their care

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45731/psn-pdf
    September 29, 2017 - example, in the case of breast cancer, screening may detect lesions that are not clinically significant, leading

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40309/psn-pdf
    April 22, 2011 - Brent James—one of the nation's leading physician quality improvement experts—discussed his use of change

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44586/psn-pdf
    June 21, 2016 - important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43571/psn-pdf
    October 01, 2014 - evidence that walkrounds improved safety culture, this practice became widely endorsed by AHRQ and other leading

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41706/psn-pdf
    November 08, 2012 - An AHRQ WebM&M commentary discusses a case of medication error leading to a preventable readmission.

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41795/psn-pdf
    September 07, 2016 - Although the details leading to the voluntary facility shutdown were not transparent, the authors suggest

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40842/psn-pdf
    September 24, 2016 - A case of an interruption leading to a medication error is discussed in this AHRQ WebM&M commentary.

  10. Survey results reveal tubing misconnections are common and underreported—Parts I and II. | PSNet

    psnet.ahrq.gov/issue/survey-results-reveal-tubing-misconnections-are-common-and-underreported-parts-i-and-ii
    December 18, 2024 - November 8, 2023 WebM&M Cases Misconnection Leading to

  11. Risk of medication errors at hospital discharge and barriers to problem resolution. | PSNet

    psnet.ahrq.gov/issue/risk-medication-errors-hospital-discharge-and-barriers-problem-resolution
    November 03, 2015 - authors reviewed discharge medication records for elderly patients to assess documentation problems leading

  12. Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors | PSNet

    psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
    May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer … initiatives, medical errors still occur frequently in these situations (with these errors sometimes leading

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851099/psn-pdf
    June 28, 2023 - Misconnection Leading to Arterial Thrombosis June 28, 2023 Bohringer C, Lee G. … Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023. … https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis The Case A 55-year-old man … The Commentary https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis by Christian … are also associated with pain on arterial injection, they are much less likely to cause thrombosis leading

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43664/psn-pdf
    September 01, 2016 - Inappropriate alarm settings, electrode failure leading to poor signal quality, and alerts for non-actionable

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46864/psn-pdf
    August 17, 2018 - However, alerts are pervasive and often irrelevant, leading patient safety experts to question whether

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39143/psn-pdf
    February 14, 2011 - impact-pharmacist-facilitated-hospital-discharge-program-quasi-experimental- study Medication errors are a leading

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45714/psn-pdf
    December 20, 2017 - national-surveillance-emergency-department-visits-outpatient-adverse-drug-events https://psnet.ahrq.gov/issue/medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46504/psn-pdf
    February 22, 2018 - how-guiding-coalitions-promote-positive-culture-change-hospitals-longitudinal-mixed-methods https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44823/psn-pdf
    February 15, 2017 - Half were coded as "general unintentional," which includes exploratory exposures and other scenarios leading

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44372/psn-pdf
    June 21, 2016 - These results add weight to concerns about unintended consequences of pay-for-performance programs leading
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