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psnet.ahrq.gov/node/49820/psn-pdf
February 01, 2018 - Returning Home Safely
February 1, 2018
Toles M. Returning Home Safely. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/returning-home-safely
The Case
A 72-year-old man was admitted to the hospital after a fall at home resulting in a right humerus fracture and
shoulder dislocation, as well as other injuries …
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Spotlight
Too Many Cooks in the Kitchen
Source and Credits
• This presentation is based on the August 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Richard P. Dutton, MD, MBA
o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
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psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
June 01, 2018 - I see this beginning to happen in medical schools, residencies, medical and professional organizations
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - fraction of that—one fiftieth or one hundredth of that when you look at the budget of AHRQ and other organizations
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psnet.ahrq.gov/periodic-issue/periodic-issue-313
October 27, 2021 - theoretic model and matrix (DEEP SCOPE; DEsigning with Ergonomic Principles – Safety as Complexity of the Organization
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psnet.ahrq.gov/periodic-issue/periodic-issue-342
May 16, 2022 - In her professional role, she provides strategic direction for the research mission of the organization
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psnet.ahrq.gov/periodic-issue/periodic-issue-410
September 27, 2023 - Patient and family complaints often highlight concerns missed by standard organization incident reporting
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psnet.ahrq.gov/periodic-issue/periodic-issue-374
December 14, 2022 - The authors advocate for enhanced use of systems-focused and organization-centric strategies to improve
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Brentwood (TN): Organization of Teratology Information
Specialists (OTIS); 1994-.
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Brentwood (TN): Organization of Teratology Information Specialists (OTIS); 1994-.
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psnet.ahrq.gov/web-mm/central-line-clot
August 04, 2021 - October 21, 2015
Perioperative safety in plastic surgery: is the World Health Organization
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psnet.ahrq.gov/node/49642/psn-pdf
December 01, 2011 - Health Electronic Data Interchange Network (NEHEN)
CEO of MA-SHARE (the Regional Health Information Organization
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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - system interventions can be implemented, but they will require support from a hospital or health care organization
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - The culture of safety: results of an organization-wide survey in 15 California hospitals.
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - a previous anesthetic even when it was performed in a different city or within another healthcare
organization
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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - These are generally readily apparent—unlike latent errors, which are features
of an organization or
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psnet.ahrq.gov/node/49600/psn-pdf
April 01, 2010 - have been multifactorial and have involved many processes, more
than one line of responsibility, and organization-wide
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psnet.ahrq.gov/web-mm/code-status-confusion
September 01, 2006 - February 17, 2017
A World Health Organization field trial assessing a proposed ICD-11
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psnet.ahrq.gov/node/33663/psn-pdf
September 15, 2008 - Structure and Organization
AHS hospitals are individually managed facilities, with local Boards of Directors
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psnet.ahrq.gov/node/850675/psn-pdf
June 14, 2023 - guide to better engage long term
care patients and families in future research.10
Partnerships at the Organization