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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - Critical Echocardiogram Result Lost to Follow-up
Citation Text:
Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/node/49523/psn-pdf
November 01, 2006 - The threat of urinary retention and having to wait hours in the emergency room in excruciating
pain
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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - The next day her daughter found her extremely weak and took her to the Emergency Department (ED).
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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - Clinical Laboratory Science has proposed a patient safety indicator focused on delayed test results in
emergency … departments due to specimen rejection. … MPH
Co-Editor-in-Chief, AHRQ’s Patient Safety Network (PSNet)
Professor of Internal Medicine and Pediatrics
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety
Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD
| August 30, 2023
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Van CM, Mossb…
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety
Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD
| August 30, 2023
Also Read the Essay
View more articles from the same authors. …
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psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures
Citation Text:
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - SPOTLIGHT CASE
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
Citation Text:
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
April 01, 2006 - satisfaction, results in resolution of medication-related problems, and reduces subsequent visits to the emergency … department.( 6 , 7 ) We in pharmacy education have been preparing our graduates for these roles. … April 24, 2018
Crowding in the Emergency Department: Challenges for the Care of Children
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psnet.ahrq.gov/web-mm/death-pca
January 06, 2017 - Death by PCA
Citation Text:
Hicks RW. Death by PCA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Dow…
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - Equally, what is acceptable in an emergency department during a mass casualty event may not be appropriate
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - In California, the nurse patient ratio in the emergency department is one nurse to four patients.
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psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
April 01, 2008 - SPOTLIGHT CASE
A "Reflexive" Diagnosis in Primary Care
Citation Text:
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
January 31, 2024 - If you’re getting a CT scan and you’ve already had one, and you go to an emergency room and they say, … This error particularly happens more frequently in pediatrics, where you have weight-based dosing.
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psnet.ahrq.gov/node/851568/psn-pdf
July 31, 2023 - weighing 71 kg with a past medical history of alcohol use disorder and prostate cancer
presented to an emergency … department (ED) 36 hours after his last alcoholic drink with signs and
symptoms of alcohol withdrawal … Pediatrics. 2016;138(6). [Available at]
30. Douglass AM, Elder J, Watson R, et al.
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psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
May 01, 2009 - safety information (medication and problem lists, allergies, etc.) to others with whom we practice (emergency … departments, consultants, hospitals).
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psnet.ahrq.gov/node/852700/psn-pdf
August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond
the Pandemic: Creating Total Systems Safety
August 30, 2023
McGaffigan P, Van CM, Mossburg S. In Conversation with.. Patricia McGaffigan about Beyond the
Pandemic: Creating Total Systems Safety . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/con…
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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx
Spotlight
The Risks of a Malpositioned Gastrostomy Tube and
Poor Communication
Source and Credits
• This presentation is based on the November 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahr…
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psnet.ahrq.gov/web-mm/see-patient-first
September 27, 2023 - The Case
A 55-year-old man with acute myeloid leukemia presented to the emergency department (