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7301. Section 6. Facilitating Change and Anticipating Challenges | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ptflow/section6.html
      July 01, 2018 - Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals Section 6. Facilitating Change and Anticipating Challenges Previous Page Next Page Table of Contents Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals Acknowledgments E…

7302. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-mar2023.pdf
      July 14, 2023 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare March Meeting Summary Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on Appropriations requested “AHRQ t…

7303. Federal Interagency Workgroup on Improving Diagnostic Safety: July Meeting Summary (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-jul2023.pdf
      November 03, 2023 - Federal Interagency Workgroup on Improving Diagnostic Safety: July Meeting Summary Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare July Meeting Summary Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on Appropriations requested that…

7304. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49456/psn-pdf
      July 12, 2004 - Glucose Roller Coaster July 1, 2004 Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/glucose-roller-coaster The Case A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was significant for dialysis-dependent, end-stage kidney d…

7305. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33876/psn-pdf
      August 01, 2018 - Building a Safety Program in a Vast Health Care Network March 1, 2019 Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network Perspective Background As hospital-based health care in the United …

7306. 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…

7307. 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…

7308. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49438/psn-pdf
      March 05, 2004 - OR Peeping March 1, 2004 Mackenzie CF. OR Peeping. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/or-peeping The Case A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete spontaneous abortion (miscarriage). At this community hospital, a new operating room (OR) su…

7309. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49487/psn-pdf
      August 21, 2005 - Surprise Wire August 21, 2005 Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/surprise-wire The Case A 39-year-old man with a history of liver disease presented to the emergency department (ED) with gastrointestinal bleeding and altered mental status. Due to his clinic…

7310. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33659/psn-pdf
      October 01, 2007 - Making Just Culture a Reality: One Organization's Approach October 1, 2007 Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach Perspective We've all been there...something goes wrong,…

7311. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49507/psn-pdf
      April 01, 2006 - Is the "Surgical Personality" a Threat to Patient Safety? April 1, 2006 Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety? PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety Case Objectives Describe the myth of the "surgical personality" Identify featu…

7312. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49442/psn-pdf
      May 01, 2004 - Missed TB May 1, 2004 FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/missed-tb The Case A 38-year-old white female with no past medical history presented to the hospital with fevers, respiratory failure, and bilateral pulmonary infiltrates. She was treated empirically w…

7313. Adding Clinical Data Elements to Administrative Data
      hcup-us.ahrq.gov/datainnovations/clinicaldata/AHRQHCUPfinalNov09BDiefenbach.jsp
      April 09, 2011 - Adding Clinical Data Elements to Administrative Data An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs…

7314. Check the Bags | PSNet
      psnet.ahrq.gov/web-mm/check-bags
      January 03, 2017 - Check the Bags Citation Text: Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

7315. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience | PSNet
      psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
      July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience Karen Frush, MD | May 1, 2005  View more articles from the same authors. Citation Text: Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…

7316. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33821/psn-pdf
      December 01, 2016 - Errors and Near Misses: What Health Care Could Learn From Aviation December 1, 2016 Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation Perspective Some of the most urg…

7317. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33834/psn-pdf
      May 22, 2017 - Opioid Overdose as a Patient Safety Problem May 22, 2017 Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem Perspective Opioids serve a valuable role in the treatment of acute pain and pain associat…

7318. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49649/psn-pdf
      March 01, 2012 - Cultural Dimensions of Depression March 1, 2012 Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/cultural-dimensions-depression The Case A 55-year-old Vietnamese man was admitted to a general medicine ward with vague complaints of inability to breathe and swallow…

7319. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850362/psn-pdf
      June 14, 2023 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital June 14, 2023 Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…

7320. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
      October 01, 2015 - PowerPoint Presentation Spotlight The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy 1 This presentation is based on the October 2015 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/ CME credit is available Commentary by: Jacob Reider,…