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psnet.ahrq.gov/issue/incivility-and-clinical-performance-teamwork-and-emotions-randomized-controlled-trial
May 22, 2013 - August 30, 2023
Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism
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psnet.ahrq.gov/issue/active-surveillance-vaccine-safety-system-detect-early-signs-adverse-events
March 29, 2010 - July 7, 2021
Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism
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psnet.ahrq.gov/issue/how-well-do-incident-reporting-systems-work-inpatient-psychiatric-units
September 05, 2018 - medication errors in psychiatry: creating a culture of safety through the use of an adverse event reporting mechanism
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psnet.ahrq.gov/issue/systematic-video-game-training-surgical-novices-improves-performance-virtual-reality
January 18, 2011 - September 30, 2011
Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism
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psnet.ahrq.gov/issue/building-framework-trust-critical-event-analysis-deaths-surgical-care
June 23, 2009 - testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism
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psnet.ahrq.gov/issue/comparison-and-interpretation-urinalysis-performed-nephrologist-versus-hospital-based
March 14, 2016 - January 12, 2022
Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism
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psnet.ahrq.gov/issue/incident-reporting-behaviours-following-francis-report-cross-sectional-survey
October 12, 2016 - February 1, 2017
Healthcare professional and patient codesign and validation of a mechanism
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psnet.ahrq.gov/issue/internal-reporting-system-improve-pharmacys-medication-distribution-process
October 31, 2017 - testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism
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psnet.ahrq.gov/issue/novel-icu-hand-over-tool-glass-door-patient-room
October 12, 2009 - Does nurse use of a standardized flowsheet to document communication with advanced providers provide a mechanism
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psnet.ahrq.gov/issue/facilitators-and-barriers-implementation-surgical-safety-checklist-ssc-integrative-review
September 07, 2016 - July 22, 2015
Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism
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psnet.ahrq.gov/issue/barriers-reporting-medication-administration-errors-and-near-misses-interview-study-nurses
September 27, 2017 - medication errors in psychiatry: creating a culture of safety through the use of an adverse event reporting mechanism
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psnet.ahrq.gov/issue/duty-hours-quality-care-and-patient-safety-general-surgery-resident-perceptions
July 02, 2014 - testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism
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psnet.ahrq.gov/issue/results-and-lessons-hospital-wide-initiative-incentivised-delivery-system-reform-improve
March 02, 2022 - March 10, 2021
Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism
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psnet.ahrq.gov/issue/resource-based-view-safety-cultures-influence-hospital-performance-moderating-role-electronic
November 17, 2021 - August 10, 2022
Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism
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psnet.ahrq.gov/issue/patients-conceptualizations-responsibility-healthcare-typology-understanding-differing
January 08, 2020 - October 9, 2019
Healthcare professional and patient codesign and validation of a mechanism
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Elizabeth Gould, NP-C, COR…
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
January 01, 2024 - episodes of vomiting;
Age 65 years or older;
Amnesia for 30 minutes or more before impact;
Dangerous mechanism … had, the ED team would likely have interpreted sledding head-first into a tree without a helmet as a mechanism … blunt head trauma (with or without neurologic abnormalities at presentation) does not consider the mechanism
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psnet.ahrq.gov/issue/iatrogenic-illness-general-medical-service-university-hospital
August 17, 2017 - May 12, 2021
Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism
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psnet.ahrq.gov/issue/accuracy-and-safety-medication-histories-obtained-time-intensive-care-unit-admission
October 20, 2021 - Study
Accuracy and safety of medication histories obtained at the time of intensive care unit admission of delirious or mechanically ventilated patients.
Citation Text:
Cicci CD, Fudzie SS, Campbell-Bright S, et al. Accuracy and safety of medication histories obtained at the time of inte…
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psnet.ahrq.gov/node/49856/psn-pdf
March 01, 2019 - Premature Extubation
March 1, 2019
Sagana R, Hyzy RC. Premature Extubation. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/premature-extubation
The Case
A 73-year-old woman with a history of carotid artery stenosis was admitted for an elective carotid
endarterectomy. The procedure was initially thought to …