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psnet.ahrq.gov/issue/potential-medical-adverse-events-associated-death-forensic-pathology-perspective
July 31, 2019 - September 25, 2019
Pediatric patient safety in the prehospital/emergency department setting
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psnet.ahrq.gov/issue/first-year-who-surgical-safety-checklist-7148-otorhinolaryngological-operations-use-and-user
October 30, 2019 - Study
First year with WHO Surgical Safety Checklist in 7148 otorhinolaryngological operations: use and user attitudes.
Citation Text:
Helmiö P, Takala A, Aaltonen L-M, et al. First year with WHO Surgical Safety Checklist in 7148 otorhinolaryngological operations: use and user attitudes…
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - Simplifying the work environment by: (i) increasing the visibility of a central line, (ii) assigning the emergency … department to plan removal of central lines placed outside the hospital in patients received on transfer
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psnet.ahrq.gov/web-mm/think-surgeon
December 04, 2024 - Case
A patient with a history of T6 paraplegia due to a motor vehicle accident was brought to the emergency … department due to delirium. … Abdominal pain and sepsis are among the most common reasons for diagnostic error in the emergency department … Diagnostic errors related to acute abdominal pain in the emergency department.
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psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
December 14, 2022 - This skill is apparent in environments such as (a) emergency departments, where it may be difficult to … Patient Safety Innovations
Suicide Prevention in an Emergency … Department Population: ED-SAFE
April 24, 2024
Annual Perspective
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psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
December 14, 2022 - This skill is apparent in environments such as (a) emergency departments, where it may be difficult to … Patient Safety Innovations
Suicide Prevention in an Emergency … Department Population: ED-SAFE
April 24, 2024
Annual Perspective
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psnet.ahrq.gov/node/836892/psn-pdf
April 07, 2022 - Delivery of end-of-life care in an
emergency department–based intensive care unit. … Boarding of critically ill patients in the emergency department. … Boarding of critically ill patients in the emergency
department. … Boarding of critically ill patients in the emergency
department. … Increasing critical care admissions from U.S. emergency
departments, 2001-2009.
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psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
November 25, 2020 - The Case
A 28-year-old woman arrived at the Emergency Department (ED) complaining of back pain and … Department. … department setting. … department image interpretation accuracy: the influence of immediate reporting by radiology. … Departments
Labor and Delivery
Health Care Providers
Quality and Safety Professionals
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psnet.ahrq.gov/node/49653/psn-pdf
May 01, 2012 - Simplifying the work environment by: (i) increasing the visibility of a central line, (ii) assigning the
emergency … department to plan removal of central lines placed outside the hospital in patients
received on transfer
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psnet.ahrq.gov/node/49742/psn-pdf
September 01, 2015 - A Fumbled Handoff to Inpatient Rehab
September 1, 2015
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
The Case
An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - diagnostic errors, including
an award to the Safer Dx team for detecting and measuring diagnostic errors in emergency … department
settings.14
The original Safer Dx Instrument was intended for research on diagnostic errors … Safer Stroke-Dx Instrument: identifying stroke
misdiagnosis in the emergency department.
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psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. … The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. … The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. … Psychosocial assessment of patients who attend an accident and emergency department with self-harm. … March 29, 2023
A review of adverse event reports from emergency departments in
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psnet.ahrq.gov/node/33880/psn-pdf
May 01, 2019 - Safety in the Prehospital Emergency Medical Services
Setting
May 1, 2019
Patterson DP, Yealy DM. Safety in the Prehospital Emergency Medical Services Setting. PSNet [internet].
2019.
https://psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
Perspective
Emergency medical services (E…
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psnet.ahrq.gov/issue/evaluating-clinical-decision-support-systems-monitoring-cpoe-order-check-override-rates
October 19, 2022 - Study
Evaluating clinical decision support systems: monitoring CPOE order check override rates in the Department of Veterans Affairs' computerized patient record system.
Citation Text:
Lin C-P, Payne TH, Nichol P, et al. Evaluating clinical decision support systems: monitoring CPOE ord…
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psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis
June 21, 2017 - Study
An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system.
Citation Text:
Hagley GW, Mills PD, Shiner B, et al. An Analysis of Adverse Events in the Rehabilitation Department: Using the Veterans Affairs Root Cause Analysis…
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psnet.ahrq.gov/issue/development-and-validation-brief-culture-safety-survey
May 26, 2021 - 2024
Patient Safety Innovations
Suicide Prevention in an Emergency … Department Population: ED-SAFE
April 24, 2024
Toward zero harm: Mackenzie Health's
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psnet.ahrq.gov/node/72693/psn-pdf
January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room
– Mixing Up the Ampules
January 29, 2021
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
The Case
A…
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psnet.ahrq.gov/perspective/safety-radiology
October 01, 2013 - a 15-center AHRQ-funded randomized trial to figure out how do we image patients best who present to emergency … departments with flank pain for suspected kidney stones and the study has a broad range of endpoints—patients … ' pain, time in the emergency department, admission to the hospital, total amount of testing and costs … people focused on a mock trial organized around the case of a woman who had repeated CT scanning in the emergency … room—all of the imaging examinations were negative—and who developed breast cancer 6 years later and
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - department (ED) by her daughter. … Bringing patients' own medications into an emergency department by ambulance: effect on prescribing accuracy … department medication errors. … Department
April 7, 2022
WebM&M Cases
Delayed … Departments
Health Care Providers
Risk Managers
Quality and Safety Professionals
View
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psnet.ahrq.gov/issue/code-debriefing-department-veterans-affairs-va-medical-team-training-program-improves
August 18, 2010 - Study
Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training Program improves the cardiopulmonary resuscitation code process.
Citation Text:
Percarpio KB, Harris FS, Hatfield BA, et al. Code debriefing from the Department of Veterans Affairs (VA) Medical Tea…