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psnet.ahrq.gov/node/33858/psn-pdf
May 01, 2018 - In Conversation With… John Halamka, MD, MS
May 1, 2018
In Conversation With… John Halamka, MD, MS. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
Editor's note: Dr. Halamka is the International Healthcare Innovation Professor at Harvard Medical
School, Chief Information …
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - SPOTLIGHT CASE
Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery
Citation Text:
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery.. PSNet [internet]…
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - In Conversation With... David Gruen, MD
January 31, 2020
Also Read the Essay
Citation Text:
In Conversation With.. David Gruen, MD. PSNet [internet]. 2020.In Conversation With... David Gruen, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research an…
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - Artificial Intelligence and Diagnostic Errors
January 31, 2020
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Hea…
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psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH
November 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 200…
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions
Lindsay E. Nicolle, MD | November 1, 2008
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Nicolle LE. Health Care–Acquired Urinary Tract Infection: The Pr…
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psnet.ahrq.gov/node/49470/psn-pdf
December 01, 2004 - Discharge Fumbles
December 1, 2004
Forster AJ. Discharge Fumbles. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/discharge-fumbles
Case Objectives
List the types of adverse events that occur at discharge
Identify the characteristics that identify patients at high risk for errors at discharge
Understand th…
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psnet.ahrq.gov/node/857260/psn-pdf
November 30, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP
(Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
November 30, 2023
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2
Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/when…
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psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - Harm From Alarm Fatigue
December 1, 2015
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/harm-alarm-fatigue
Case Objectives
Define alarm fatigue and describe potential errors that can occur due to alarm fatigue.
Identify federal and national agencies focusing on …
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psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
February 26, 2025 - In Conversation with...Diane Rydrych, MA
June 1, 2007
Citation Text:
In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007.In Conversation with...Diane Rydrych, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department…
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psnet.ahrq.gov/web-mm/wrong-channel
February 01, 2003 - The Wrong Channel
Citation Text:
Gosbee JW. The Wrong Channel
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfer Troubles
1
2
Source and Credits
This presentation is based on the June 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…
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psnet.ahrq.gov/node/33717/psn-pdf
September 01, 2011 - Incident Reporting: More Attention to the Safety Action
Feedback Loop, Please
September 1, 2011
Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet
[internet]. 2011.
https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
…
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psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - Dangerous Dialysis
October 1, 2010
Holley JL. Dangerous Dialysis . PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/dangerous-dialysis
Case Objectives
List common errors that occur in dialysis units.
Describe steps that can be taken by dialysis units to prevent these common errors.
Describe the role of the …
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psnet.ahrq.gov/node/49713/psn-pdf
June 01, 2014 - CVP, thereby decreasing the pressure
gradient that promotes air embolism formation.(5,8,9) The Table lists … risks, while CVC removal has not.(11) Based on this bias, CVC insertion has long been included in lists
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psnet.ahrq.gov/node/49489/psn-pdf
September 01, 2005 - setting, providers
should review with the patient and/or responsible family member previous medication lists … setting, providers should review with the patient and/or responsible family member previous
medication lists
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - hospitals have worked with ambulance staff to remind them to pick up prescription bottles or medication
lists … Individually, patients should be encouraged
to carry their medication lists and present them at each
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Similar to the Armor study, this one found discrepancies between hospital discharge and home medication lists … Both studies indicate that creating a new approach to reconciling patients' discharge medication lists
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psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
August 06, 2014 - The FDA also has a website that lists all current REMS drugs, and FDA-approved prescribing information … Table 2 lists several safety systems that can be considered.( 8 ) Some of the strategies focus on individuals
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - that require urgent attention
• Presenting results in the context of previous results, medication lists … , and problem lists
• Forwarding capability and allowing the use of surrogates during planned absences