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psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
February 01, 2019 - unintended consequence was that test became disproportionately important because there were no other objective
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psnet.ahrq.gov/perspective/conversation-james-augustine-md
July 28, 2021 - organizations are considering the expansion of EMS’ role to provide more direct care in the community with the objective
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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - , if a woman has been pushing for 3 hours, then 4 hours, then 5 hours when it's 2:00 AM, there's no objective
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psnet.ahrq.gov/issue/improving-safety-operating-room-systematic-literature-review-retained-surgical-sponges
March 05, 2025 - Review
Improving safety in the operating room: a systematic literature review of retained surgical sponges.
Citation Text:
Wan W, Le T, Riskin L, et al. Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol. 2009;22(…
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psnet.ahrq.gov/issue/designing-safer-process-prevent-retained-surgical-sponges-healthcare-failure-mode-and-effect
April 27, 2019 - Study
Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis.
Citation Text:
Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):1…
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - Guidelines for the granting of endoscopic privileges recommend the use of objective criteria and direct … Institutions should, whenever possible, use objective criteria and direct observation to assess competence
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psnet.ahrq.gov/issue/application-engineering-problem-solving-methodology-address-persistent-problems-patient
March 18, 2020 - Study
Application of an engineering problem-solving methodology to address persistent problems in patient safety: a case study on retained surgical sponges after surgery.
Citation Text:
Anderson DE, Watts B. Application of an engineering problem-solving methodology to address persistent…
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx
Spotlight
Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See…
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psnet.ahrq.gov/node/49843/psn-pdf
October 01, 2018 - Spotlight: Overdiagnosis and Delay: Challenges in Sepsis
Diagnosis
October 1, 2018
Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
Case Objectives
Realize the im…
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psnet.ahrq.gov/node/49534/psn-pdf
May 01, 2007 - Antiseizure Medication Disorder
May 1, 2007
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
Case Objectives
Appreciate the challenges of safe use of antiepileptic medications.
Identify phenytoin toxicity.
Understand the pharmaco…
-
psnet.ahrq.gov/node/33748/psn-pdf
April 01, 2013 - In Conversation With… Christopher P. Landrigan, MD,
MPH
April 1, 2013
In Conversation With… Christopher P. Landrigan, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
Editor's note: Christopher P. Landrigan, MD, is Associate Professor of Medicine and …
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psnet.ahrq.gov/node/49723/psn-pdf
January 01, 2015 - Monitoring Fetal Health
January 1, 2015
Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/monitoring-fetal-health
Case Objectives
Define fetal heart rate monitoring.
Describe the current state of evidence regarding fetal heart rate monitoring.
List the known …
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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Despite Clues, Failed to Rescue
August 1, 2017
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
Case Objectives
Define failure to rescue.
Identify the main contributors to failure-to-rescue events.
Appreciate the ongoing areas of scien…
-
psnet.ahrq.gov/node/49831/psn-pdf
June 01, 2018 - Chest Pain in a Rural Hospital
June 1, 2018
MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
Case Objectives
Recognize that a significant proportion of the Unites States population receives care in rural safety
net emergency dep…
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psnet.ahrq.gov/node/33786/psn-pdf
May 01, 2015 - seen increased interest in developing validated
assessment tools, which should lay a foundation for objective
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psnet.ahrq.gov/node/36247/psn-pdf
February 13, 2008 - Counting for patient safety.
February 13, 2008
Watson DS. Counting for patient safety. AORN J. 2006;84(2):273-5.
https://psnet.ahrq.gov/issue/counting-patient-safety
The author discusses recommended policies and practices for minimizing the risk of retained foreign
objects.
https://psnet.ahrq.gov/issue/counting-p…
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psnet.ahrq.gov/issue/risk-factors-retained-surgical-items-meta-analysis-and-proposed-risk-stratification-system
January 18, 2013 - Study
Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system.
Citation Text:
Moffatt-Bruce SD, Cook CH, Steinberg SM, et al. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. J Surg Res. 2014;190(…
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psnet.ahrq.gov/issue/prevalence-and-characteristics-interruptions-and-distractions-during-surgical-counts
March 09, 2016 - Study
Prevalence and characteristics of interruptions and distractions during surgical counts.
Citation Text:
Bubric KA, Biesbroek SL, Laberge JC, et al. Prevalence and characteristics of interruptions and distractions during surgical counts. Jt Comm J Qual Patient Saf. 2021;47(9):556-56…
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psnet.ahrq.gov/issue/prevention-retained-surgical-sponges-decision-analytic-model-predicting-relative-cost
January 04, 2010 - Study
Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness.
Citation Text:
Regenbogen SE, Greenberg CC, Resch SC, et al. Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness. Surger…
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psnet.ahrq.gov/node/35406/psn-pdf
September 10, 2009 - Maintain accountability in patient safety efforts.
September 10, 2009
Spath P. Maintain accountability in patient safety efforts. Hospital peer review. 2005;30(9):129-32.
https://psnet.ahrq.gov/issue/maintain-accountability-patient-safety-efforts
To develop an accountability initiative, the author recommends settin…