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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - Past issues of the PSNet Weekly Update are
available to browse. … WebM&M presents current and past monthly issues of Cases & Commentaries and
Perspectives … Organization-wide survey scores improved 12 months after the coaching program was launched.
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psnet.ahrq.gov/issue/adverse-drug-events-hospitalized-patients-excess-length-stay-extra-costs-and-attributable
February 10, 2011 - Related Resources
Parenteral nutrition errors and potential errors reported over the past … May 18, 2016
Opioid prescribing and potential overdose errors among children 0 to 36 months
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psnet.ahrq.gov/primers-0
March 15, 2025 - The use and sophistication of these systems have grown markedly over the past decade,... … Published Date
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Additional … The use and sophistication of these systems have grown markedly over the past decade, due to widespread
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psnet.ahrq.gov/node/49761/psn-pdf
May 01, 2016 - month later and reported fatigue, a chronic nonproductive cough,
and a 17-pound weight loss over the past … The patient missed this follow-up appointment and ultimately returned to the clinic several months later … In the past, detailed
conversation between services to share patient history and discuss study results … (b) 6 months.Consecutive CT
images through left lower lobe obtained at same anatomic level after 6 months
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psnet.ahrq.gov/node/49567/psn-pdf
September 01, 2008 - Case A: Part 1
A 55-year-old male immigrant with no significant past medical history came to the … She is
postmenopausal, has an unremarkable past medical history and no allergies, and her only medications … She has not left her home for
the past 6 months.
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psnet.ahrq.gov/issue/health-informatics-healthcare-quality-and-safety-and-healthcare-simulation-new-triad-advance
April 28, 2021 - September 21, 2022
Adverse events in infants less than 6 months of age after ambulatory
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psnet.ahrq.gov/node/49860/psn-pdf
April 01, 2019 - web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
The Case
An 82-year-old man with a past … After
discussion with his family, the patient was ultimately transitioned to hospice and died several months … age 60 and older found that patients operated on within 48 hours had a 20%
lower mortality within 12 months … availability, and broad organizational challenges.(8)
The fact that patients often don't die for weeks or months … decreased mortality rates, shorter length of stay, and improved
functional independence at 4 and 12 months
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psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
April 24, 2018 - month later and reported fatigue, a chronic nonproductive cough, and a 17-pound weight loss over the past … The patient missed this follow-up appointment and ultimately returned to the clinic several months later … In the past, detailed conversation between services to share patient history and discuss study results … (b) 6 months.Consecutive CT images through left lower lobe obtained at same anatomic level after 6 months
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psnet.ahrq.gov/node/43436/psn-pdf
August 13, 2014 - A past AHRQ WebM&M commentary describes pitfalls of handoffs.
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psnet.ahrq.gov/node/33801/psn-pdf
February 01, 2016 - and
my professional work would change so greatly and include so many more clerical tasks than in the past … say this is real—that physicians actually
are less happy and more burned out than they were in the past … I went back to visit them several
months later. … of a 44-year-old patient with emphysema who
had been hospitalized several times in the previous 4 months … When
people have thought of wellness committees in the past, it's probably focused more on individual
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psnet.ahrq.gov/node/47735/psn-pdf
June 24, 2019 - A past PSNet perspective discussed the tragic error involving Betsy Lehman,
who died due to an inadvertent
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psnet.ahrq.gov/innovation/team-developed-care-plan-and-ongoing-care-management-social-workers-and-nurse
July 23, 2024 - In comparing the 12 months before the GRACE intervention and the 25 months after the intervention, GRACE … adapted to include adults of all ages that were at high-risk (>5 ED visits or >2 hospitalizations in the past … after enrollment compared to 6 months before enrollment. … less than 200 percent of the Federal poverty level, have had one or more primary care visits in the past … ago increased from 36% at enrollment to 64% at 9 months (p = 0.002).
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psnet.ahrq.gov/node/33610/psn-pdf
April 01, 2005 - In the next few months,
https://psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet … Luckily, that has changed over the past few years.
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psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
February 26, 2025 - and my professional work would change so greatly and include so many more clerical tasks than in the past … say this is real—that physicians actually are less happy and more burned out than they were in the past … I went back to visit them several months later. … The physician brought all those team members to bear on that patient's care, and after 4 or 5 more months … When people have thought of wellness committees in the past, it's probably focused more on individual
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psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
November 13, 2024 - in seven staff members (175/1,160) reported they had experienced a patient safety event within the past … Professional experience ranged between 6 months and 36 years (mean = 13.5 years). … Time lapse since the unanticipated clinical event ranged from 3 weeks to 44 months (mean = 14 months) … , length of professional relationships, cases that involved pediatric patients, and the clinician's past
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psnet.ahrq.gov/perspective/update-safety-culture
January 22, 2020 - learning and driving improvement through debriefings.( 1 )
Collecting safety culture data for the past … In one system, never events occurred once every 38 months when more than 60% of surgical suite personnel … perceived safety as good or excellent, versus once every 12 months in surgical areas with scores below
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psnet.ahrq.gov/issue/outcomes-emergency-department-patients-presenting-adverse-drug-events
April 22, 2011 - A past AHRQ WebM&M perspective discusses the broader aspects of providing safe care in the emergency
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psnet.ahrq.gov/node/49571/psn-pdf
October 01, 2008 - The child was delivered 2 months
prematurely (likely due to domestic violence) in Puerto Rico. … She had an intracerebral hemorrhage and was
in the neonatal intensive care unit (NICU) for 6 months. … mother stated that the child had been seen twice in a family
practice office for "well checks" over the past
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psnet.ahrq.gov/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
May 26, 2021 - elevated,” although he did well with no known instances of suicidality or suicide attempts in the next six months … made suicide plans and 1.4 million attempted suicide with suicide rates rising every year over the past … two decades. 1 While this past year has been an exception, in that suicide rates slightly decreased … 9s showed that a positive screen on question #9 was associated with an increased risk over days to months … Suicides drop during past year of pandemic, study finds. May 20, 2021.
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psnet.ahrq.gov/node/47150/psn-pdf
November 21, 2018 - A past PSNet perspective discussed the use of risk-adjusted mortality
as part of a safety measurement