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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - A SIRS (systemic inflammatory response syndrome) alert occurred later in the afternoon due to
hypotension
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - Patient outreach
occurred in waves with two attempts.
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - It occurred to me that maybe
we didn't understand this phenomenon well enough.
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psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - apparent if the CSI is performed within 3 months of surgery, with less risk of infection if the injection occurred
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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - apparent if the CSI is performed within 3
months of surgery, with less risk of infection if the injection occurred
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psnet.ahrq.gov/innovation/implementing-watcher-program-improve-timeliness-recognition-deterioration-hospitalized
June 30, 2021 - EMERGING INNOVATIONS
Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children
Citation Text:
Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children Evans S, Green A, Roberson A, et al. …
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psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - particular diagnosis, based on initial information, to the exclusion of other more likely diagnoses, as occurred
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psnet.ahrq.gov/perspective/what-makes-good-checklist
October 01, 2010 - Most aviation checklist errors occurred immediately after an interruption to the checklist or when the
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - Most aviation checklist errors occurred immediately after an interruption to the checklist or when the
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psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
March 01, 2014 - A substantial portion of the harm from errors occurred in the form of preventable health care–associated
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psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - particular diagnosis, based on initial information, to the
exclusion of other more likely diagnoses, as occurred
-
psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - Premature Closure: Was It Just Syncope?
November 25, 2020
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
January 01, 2022 - Spotlight
Spotlight
Perioperative Anaphylaxis After Insertion of
a Latex Drain in a Patient with Known Latex
Allergy
Source and Credits
• This presentation is based on the August 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by K…
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psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx
Spotlight
Failure to Ensure Patient Safety Leads to Patient Falls in
Nursing Homes
Source and Credits
• This presentation is based on the April 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/we…
-
psnet.ahrq.gov/node/49714/psn-pdf
August 21, 2014 - Pitfalls in Diagnosing Necrotizing Fasciitis
August 21, 2014
Goh T, Goh LG. Pitfalls in Diagnosing Necrotizing Fasciitis. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
Case Objectives
State the epidemiology of necrotizing fasciitis.
Appreciate the high mortality a…
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - Care Managers Use Software-Aided Medication Review
Protocol for Frail, Community-Dwelling Seniors, Leading
to More Appropriate Medication Use
March 31, 2021
https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-
community-dwelling
Summary
Care management staff (such …
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - SPOTLIGHT CASE
What Happened on Telemetry?
Citation Text:
Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNo…
-
psnet.ahrq.gov/perspective/equity-patient-safety
September 24, 2024 - Annual Perspective
Equity in Patient Safety
Angela D. Thomas, DrPH, MPH, MBA; Merton Lee, PhD, PharmD; Sarah Mossburg, RN, PhD
| March 27, 2024
View more articles from the same authors.
Citation Text:
Thomas A, Lee M, Mossburg S. Equity in Patient Safety. …
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - SPOTLIGHT CASE
A Fatal Twist in Pseudohyperkalemia
Citation Text:
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
…
-
psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
October 31, 2023 - SPOTLIGHT CASE
Robotic Surgery: Risks vs. Rewards
Citation Text:
Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Googl…