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psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx
Spotlight
When the Lytes Go Out: A Case
of Inpatient Cardiac Arrest
Source and Credits
• This presentation is based on the September 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psne…
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psnet.ahrq.gov/node/49590/psn-pdf
January 01, 2010 - Is the Admission Drug Dose Too Low?
August 1, 2009
Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
The Case
A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to
the hospit…
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psnet.ahrq.gov/node/60169/psn-pdf
March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration
errors in the operating room.
March 25, 2020
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…
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psnet.ahrq.gov/node/49578/psn-pdf
January 01, 2009 - Hospital Admission Due to High-Dose Methotrexate Drug
Interaction
January 1, 2009
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
The Case
A 40-year-old wo…
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psnet.ahrq.gov/node/49387/psn-pdf
February 01, 2003 - Patient Mix-Up
February 1, 2003
Shojania KG. Patient Mix-Up. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/patient-mix
The Case
Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general
medical service at an academic medical center. Overnight, another man wit…
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psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
April 01, 2009 - Commission issued its 1998 Sentinel Alert about keeping concentrated potassium chloride only in hospital pharmacies … ( 11 ) found that delays in receiving dilute solutions from the pharmacy turned ICUs into de facto pharmacies
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psnet.ahrq.gov/issue/readiness-report-medical-treatment-errors-effects-safety-procedures-safety-information-and
July 11, 2007 - Study
Readiness to report medical treatment errors: the effects of safety procedures, safety information, and priority of safety.
Citation Text:
Naveh E, Katz-Navon T, Stern Z. Readiness to report medical treatment errors: the effects of safety procedures, safety information, and prior…
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psnet.ahrq.gov/issue/impact-sleep-deprivation-product-quality-and-procedure-effectiveness-laparoscopic-physical
June 03, 2020 - Study
The impact of sleep deprivation on product quality and procedure effectiveness in a laparoscopic physical simulator: a randomized controlled trial.
Citation Text:
Uchal M, Tjugum J, Martinsen E, et al. The impact of sleep deprivation on product quality and procedure effectivene…
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psnet.ahrq.gov/issue/medication-errors-causes-analysis-home-care-setting-systematic-review
August 17, 2022 - Review
Medication errors' causes analysis in home care setting: a systematic review.
Citation Text:
Dionisi S, Di Simone E, Liquori G, et al. Medication errors' causes analysis in home care setting: A systematic review. Public Health Nurs. 2022;39(4):876-897. doi:10.1111/phn.13037.
Cop…
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psnet.ahrq.gov/issue/role-organizational-and-professional-cultures-medication-safety-scoping-review-literature
February 12, 2020 - Review
The role of organizational and professional cultures in medication safety: a scoping review of the literature.
Citation Text:
Machen S, Jani Y, Turner S, et al. The role of organizational and professional cultures in medication safety: a scoping review of the literature. Int J Hea…
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psnet.ahrq.gov/issue/influence-electronic-health-record-design-usability-and-medication-safety-systematic-review
July 19, 2023 - Review
The influence of electronic health record design on usability and medication safety: systematic review.
Citation Text:
Cahill M, Cleary BJ, Cullinan S. The influence of electronic health record design on usability and medication safety: systematic review. BMC Health Serv Res. 2025…
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psnet.ahrq.gov/issue/relationship-between-professional-burnout-and-quality-and-safety-healthcare-meta-analysis
April 24, 2018 - Review
Classic
The relationship between professional burnout and quality and safety in healthcare: a meta-analysis.
Citation Text:
Salyers MP, Bonfils KA, Luther L, et al. The Relationship Between Professional Burnout and Quality and Safety in Healthcare: A Meta…
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psnet.ahrq.gov/issue/multidisciplinary-approaches-reducing-error-and-risk-patient-care-setting
January 05, 2017 - Study
Classic
Multidisciplinary approaches to reducing error and risk in a patient care setting.
Citation Text:
Connor M, Ponte PR, Conway JB. Multidisciplinary approaches to reducing error and risk in a patient care setting. Crit Care Nurs Clin North Am. 2002…
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psnet.ahrq.gov/issue/biased-language-simulated-handoffs-and-clinician-recall-and-attitudes
June 29, 2022 - Study
Biased language in simulated handoffs and clinician recall and attitudes.
Citation Text:
Wesevich A, Langan E, Fridman I, et al. Biased language in simulated handoffs and clinician recall and attitudes. JAMA Netw Open. 2024;7(12):e2450172. doi:10.1001/jamanetworkopen.2024.50172.
…
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psnet.ahrq.gov/issue/call-action-next-steps-advance-diagnosis-education-health-professions
November 25, 2020 - Commentary
A call to action: next steps to advance diagnosis education in the health professions.
Citation Text:
Graber ML, Holmboe ES, Stanley J, et al. A call to action: next steps to advance diagnosis education in the health professions. Diagnosis (Berl). 2022;9(2):166-175. doi:10.151…
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psnet.ahrq.gov/issue/preventable-hospital-admissions-related-medication-harm-cost-analysis-harm-study
April 27, 2022 - Study
Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study.
Citation Text:
Leendertse AJ, van den Bemt PMLA, Poolman JB, et al. Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study. Value Health. 2011;14(1)…
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psnet.ahrq.gov/issue/targeted-implementation-comprehensive-unit-based-safety-program-through-assessment-safety
November 20, 2015 - Study
Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections.
Citation Text:
Richter J, McAlearney AS. Targeted implementation of the Comprehensive Unit-Based Safety Program…
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psnet.ahrq.gov/issue/implementation-high-reliability-organization-framework-large-integrated-health-care-system
July 14, 2018 - Study
Implementation of a high-reliability organization framework in a large integrated health care system: a pre-post quasi-experimental quality improvement project.
Citation Text:
Sawyer AM, Thiyarajan S, Essen KE, et al. Implementation of a high-reliability organization framework in a…
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psnet.ahrq.gov/issue/us-poison-control-center-calls-infants-6-months-age-and-younger
November 16, 2022 - Study
US poison control center calls for infants 6 months of age and younger.
Citation Text:
Kang M, Brooks DE. US Poison Control Center Calls for Infants 6 Months of Age and Younger. Pediatrics. 2016;137(2):e20151865. doi:10.1542/peds.2015-1865.
Copy Citation
Format:
DOI G…
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psnet.ahrq.gov/issue/evaluation-electronic-health-record-implementation-pharmacist-interventions-related-oral
January 25, 2023 - Study
Evaluation of electronic health record implementation on pharmacist interventions related to oral chemotherapy management.
Citation Text:
Finn A, Bondarenka C, Edwards K, et al. Evaluation of electronic health record implementation on pharmacist interventions related to oral chemot…