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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - When oxygen is absent, anaerobic respiration very rapidly leads to lactic acidosis and cardiac arrest
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psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
June 01, 2017 - available.( 1 ) Most of the weekend effect has been attributed to this decreased on-site staffing, which leads
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads
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psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
January 01, 2024 - Spotlight
Spotlight
Do Not Miss Sepsis Needles in Viral Haystacks!
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Michelle Hamline, MD, PhD, MAS and Ulfat
Shaikh, MD, M…
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psnet.ahrq.gov/node/841566/psn-pdf
December 14, 2022 - In Conversation With... Dr. Michelle Schreiber on
Measuring Patient Safety
December 14, 2022
In Conversation With.. Dr. Michelle Schreiber on Measuring Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
Editor’s Note: Michelle Schr…
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psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
December 01, 2014 - In Conversation With… Edward Kelley, PhD
December 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Edward Kelley, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
…
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psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
December 07, 2020 - In Conversation With... Katie J. Suda, PharmD, MS
December 7, 2020
Also Read the Essay
Citation Text:
In Conversation With.. Katie J. Suda, PharmD, MS . PSNet [internet]. 2020.In Conversation With... Katie J. Suda, PharmD, MS . PSNet [internet]. Rockville (MD): …
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - SPOTLIGHT CASE
Some Patients Can't Wait: Improving Timeliness of Emergency Department Care
Citation Text:
Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…
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psnet.ahrq.gov/issue/enhancing-teamwork-communication-and-patient-safety-responsiveness-paediatric-intensive-care
March 10, 2021 - Study
Enhancing teamwork communication and patient safety responsiveness in a paediatric intensive care unit using the daily safety huddle tool.
Citation Text:
Aldawood F, Kazzaz Y, AlShehri A, et al. Enhancing teamwork communication and patient safety responsiveness in a paediatric inte…
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psnet.ahrq.gov/issue/what-has-been-impact-covid-19-safety-culture-case-study-large-metropolitan-teaching-hospital
May 05, 2021 - Study
What has been the impact of Covid-19 on safety culture? A case study from a large metropolitan healthcare trust.
Citation Text:
Denning M, Goh ET, Scott A, et al. What has been the impact of Covid-19 on safety culture? A case study from a large metropolitan healthcare trust. Int J …
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psnet.ahrq.gov/issue/safety-manchester-triage-system-detect-critically-ill-children-emergency-department
October 18, 2023 - Study
Safety of the Manchester Triage System to detect critically ill children at the emergency department.
Citation Text:
Zachariasse JM, Kuiper JW, de Hoog M, et al. Safety of the Manchester Triage System to Detect Critically Ill Children at the Emergency Department. J Pediatr. 2016;17…
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psnet.ahrq.gov/issue/electronic-health-record-usability-issues-and-potential-contribution-patient-harm
July 07, 2021 - Study
Classic
Electronic health record usability issues and potential contribution to patient harm.
Citation Text:
Howe JL, Adams KT, Hettinger Z, et al. Electronic Health Record Usability Issues and Potential Contribution to Patient Harm. JAMA. 2018;319(12):127…
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psnet.ahrq.gov/issue/association-changing-hospital-readmission-rates-mortality-rates-after-hospital-discharge
August 20, 2018 - Study
Classic
Association of changing hospital readmission rates with mortality rates after hospital discharge.
Citation Text:
Dharmarajan K, Wang Y, Lin Z, et al. Association of Changing Hospital Readmission Rates With Mortality Rates After Hospital Discharge. …
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psnet.ahrq.gov/issue/diagnostic-errors-intensive-care-unit-systematic-review-autopsy-studies
March 10, 2021 - Review
Diagnostic errors in the intensive care unit: a systematic review of autopsy studies.
Citation Text:
Winters BD, Custer J, Galvagno SM, et al. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf. 2012;21(11):894-902. doi:10.1136/bmj…
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psnet.ahrq.gov/issue/review-alleged-patient-deaths-patient-wait-times-and-scheduling-practices-phoenix-va-health
May 01, 2015 - Book/Report
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.
Citation Text:
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System. Washington, DC: VA Office o…
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psnet.ahrq.gov/issue/concordance-urgent-referral-guidelines-patients-presenting-any-six-alarm-features-possible
February 17, 2021 - Study
Concordance with urgent referral guidelines in patients presenting with any of six ‘alarm’ features of possible cancer: a retrospective cohort study using linked primary care records.
Citation Text:
Wiering B, Lyratzopoulos G, Hamilton W, et al. Concordance with urgent referral gui…
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psnet.ahrq.gov/issue/relationship-between-state-malpractice-environment-and-quality-health-care-united-states
June 21, 2017 - Study
Relationship between state malpractice environment and quality of health care in the United States.
Citation Text:
Bilimoria KY, Chung JW, Minami CA, et al. Relationship Between State Malpractice Environment and Quality of Health Care in the United States. Jt Comm J Qual Patient Sa…
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psnet.ahrq.gov/issue/physician-intent-pharmacy-label-prevalence-and-description-discrepancies-cross-sectional
July 22, 2020 - Study
From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions.
Citation Text:
Cochran GL, Klepser DG, Morien M, et al. From physician intent to the pharmacy label: prevalence and description o…
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psnet.ahrq.gov/issue/national-cost-adverse-drug-events-resulting-inappropriate-medication-related-alert-overrides
July 02, 2019 - Study
The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States.
Citation Text:
Slight SP, Seger DL, Franz C, et al. The national cost of adverse drug events resulting from inappropriate medication-related alert override…
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psnet.ahrq.gov/issue/association-2011-acgme-resident-duty-hour-reform-general-surgery-patient-outcomes-and
September 09, 2015 - Study
Classic
Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance.
Citation Text:
Rajaram R, Chung JW, Jones AT, et al. Association of the 2011 ACGME resident duty hour reform wi…