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8181. Triage Time Bomb | PSNet
      psnet.ahrq.gov/web-mm/triage-time-bomb
      September 01, 2008 - In the end, of course, these measures must be placed in the context of the broader health care environment

8182. Chest Tube Complications | PSNet
      psnet.ahrq.gov/web-mm/chest-tube-complications
      September 27, 2023 - Despite these measures, the patient did not recover spontaneous circulation for more than 30 minutes

8183. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60652/psn-pdf
      June 29, 2020 - We’ve heard about some measures being taken to allow for less exposure within a traditional dispensing

8184. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49462/psn-pdf
      October 01, 2004 - Ventilation with 100% CO2 would rapidly cause a cardiac arrest in the patient, and the usual resuscitative measures

8185. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error | PSNet
      psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
      July 30, 2020 - April 17, 2013 Repurposing clinical decision support system data to measure dosing errors

8186. In Conversation with...Eric Coleman, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
      December 01, 2007 - something interesting about the fundamental role of measurement: that there are no real performance measures … If performance measures suddenly materialized and showed that we really stink at moving information from … hospitals to skilled nursing facilities or to home, what's the magic in those measures? … value of having community-wide or even nationwide quality measurements and public reporting of those measures … measure of their transition experience.

8187. Care Transitions | PSNet
      psnet.ahrq.gov/perspective/care-transitions
      December 01, 2007 - working with the American College of Physicians and other organizations to develop care transition measures … something interesting about the fundamental role of measurement: that there are no real performance measures … If performance measures suddenly materialized and showed that we really stink at moving information from … hospitals to skilled nursing facilities or to home, what's the magic in those measures? … measure of their transition experience.

8188. Discharged Blindly | PSNet
      psnet.ahrq.gov/web-mm/discharged-blindly
      October 26, 2022 - Discharged Blindly Citation Text: Iezzoni LI. Discharged Blindly. 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 RIS…

8189. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867655/psn-pdf
      February 26, 2025 - Learning Health Systems for Patient Safety February 26, 2025 Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety Despite an observable decrease in adverse events in health care over time, rat…

8190. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49770/psn-pdf
      September 01, 2016 - Wrong-Time Error With High-Alert Medication September 1, 2016 Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication The Case A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…

8191. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
      May 01, 2012 - Spotlight Case July 2008 Spotlight Case The Perils of Cross Coverage * * Source and Credits This presentation is based on the May 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …

8192. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49860/psn-pdf
      April 01, 2019 - Hip Fractures in Older Patients: the Case for Geriatrics Comanagement April 1, 2019 Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement The Case An 82-year-old man …

8193. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33808/psn-pdf
      May 01, 2016 - Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue May 1, 2016 Jacques S, Williams E. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue Perspective Alarm fatigue occurs whe…

8194. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49463/psn-pdf
      October 14, 2004 - Moved Too Soon October 1, 2004 Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/moved-too-soon The Case A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours after arriving, while the patient was still groggy from anesthesia, a nurs…

8195. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49659/psn-pdf
      July 01, 2012 - Sloppy and Paste July 1, 2012 Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/sloppy-and-paste The Case A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new onset chest pain. The ED physician reviewed the patient's electronic me…

8196. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49617/psn-pdf
      January 01, 2011 - Failure to Reevaluate December 1, 2010 Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/failure-reevaluate The Case A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community hospital developed methicillin-resistant staphylococc…

8197. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49623/psn-pdf
      March 01, 2011 - Are We Pushing Graduate Nurses Too Fast? March 1, 2011 Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast The Case A middle-aged man was admitted to the surgical intensive care unit (SICU) following a complex surgical…

8198. Spotlight Case (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
      August 01, 2012 - Spotlight Case Spotlight Case No News May Not Be Good News 1 2 Source and Credits This presentation is based on the August 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…

8199. Lethal Cap | PSNet
      psnet.ahrq.gov/web-mm/lethal-cap
      December 19, 2018 - Lethal Cap Citation Text: Schillinger D. Lethal Cap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Do…

8200. Ruptured Heterotopic Pregnancy | PSNet
      psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy
      August 16, 2023 - Ruptured Heterotopic Pregnancy Citation Text: Cedars MI. Ruptured Heterotopic Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…