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psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
August 21, 2007 - Identify measures for reducing risks related to patient wandering. … that raise their risk.( 1 ) Physical security HCFs may choose to implement physical security measures … A more complete discussion of patient assessments and physical security measures can be found in a previous … Some HCFs take added measures including issuing a specially colored "Patient Off Unit" hall pass to patients … Response procedures Even if some preventive measures above are implemented, patients may still wander
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psnet.ahrq.gov/node/33697/psn-pdf
June 01, 2010 - Today's safety efforts are focused on specific disease performance
measures such as myocardial infarction … (time to cardiac catheterization laboratory) or pneumonia
measures (time to antibiotics). … There may also be unintended consequences of poorly designed
measures, as described by Wachter and colleagues … overall system of care and that takes system performance
and well-designed specific disease performance measures … Public reporting of antibiotic timing in patients with
pneumonia: lessons from a flawed performance measure
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psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
February 01, 2019 - consequence was that test became disproportionately important because there were no other objective measures
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psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
January 01, 2014 - SPOTLIGHT CASE
Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad
Citation Text:
Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - SPOTLIGHT CASE
The Missing Abscess: Radiology Reads in the Digital Era
Citation Text:
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33583/psn-pdf
March 01, 2023 - Simulation Training
March 1, 2023
Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/simulation-training
Originally published in 2014 by researchers at the University of California, San Francisco. Updated in
March 2023, by Jennifer J. Edwards, MS, RN, CHSE…
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - SPOTLIGHT CASE
Diagnosing Diagnostic Mistakes
Citation Text:
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google S…
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psnet.ahrq.gov/web-mm/empty-bag
June 01, 2018 - The Empty Bag
Citation Text:
Vincent C. The Empty Bag. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - Do Not Disturb!
October 1, 2007
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/do-not-disturb
Case Objectives
Define professionalism.
Discuss behaviors associated with lack of professionalism.
Outline steps one should take if a significant breach of professionalism is …
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psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures
Citation Text:
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/node/49651/psn-pdf
May 01, 2012 - The Perils of Cross Coverage
May 1, 2012
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/perils-cross-coverage
Case Objectives
Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and
care transitions.
Describe ed…
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - SPOTLIGHT CASE
Errors in Sepsis Management
Citation Text:
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X…
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psnet.ahrq.gov/node/49648/psn-pdf
March 01, 2012 - Postdischarge Follow-Up Phone Call
March 1, 2012
Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
Case Objectives
Understand why preventing readmissions through postdischarge phone calls is important.
Describe evidence su…
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psnet.ahrq.gov/node/60865/psn-pdf
August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-
BC-FACHE
August 31, 2020
In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
Editor’s Note: Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is …
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psnet.ahrq.gov/issue/effect-drug-concentration-expression-epinephrine-dosing-errors-randomized-trial
August 27, 2008 - April 12, 2023
Development of patient safety measures to identify inappropriate diagnosis … Missed medication doses in hospitalised patients: a descriptive account of quality improvement measures
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psnet.ahrq.gov/issue/impact-individual-and-team-features-patient-safety-climate-survey-family-practices
January 08, 2014 - May 1, 2024
Strength of safety measures introduced by medical practices to prevent a … Better medical office safety culture is not associated with better scores on quality measures
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psnet.ahrq.gov/issue/opioids-medicare-part-d-concerns-about-extreme-use-and-questionable-prescribing
October 29, 2008 - July 25, 2018
Request for comments on the proposed measures and 2020 targets for the … National Action Plan for Adverse Drug Event Prevention: inpatient and outpatient measures for reduction
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psnet.ahrq.gov/issue/systematic-review-patient-safety-interventions-dentistry
April 25, 2018 - safety of disabled patients: proposal for a methodology for analysis of health care risks and specific measures … Fundamentals of patient safety, the safety culture and implementation of patient safety measures in dental
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psnet.ahrq.gov/issue/chemotherapy-patients-perceptions-drug-administration-safety
April 14, 2010 - December 4, 2024
Strength of safety measures introduced by medical practices to prevent … associated with self-reported commitment to, subjective norms toward, and knowledge about preventive measures
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psnet.ahrq.gov/issue/evidence-based-organization-and-patient-safety-strategies-european-hospitals
January 20, 2016 - 16, 2015
Is the maturity of hospitals' quality improvement systems associated with measures … 24, 2012
Is the maturity of hospitals' quality improvement systems associated with measures