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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - have something where no one was hurt, and it gets just as avid and thorough an analysis and action plan
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psnet.ahrq.gov/node/60744/psn-pdf
July 29, 2020 - hospitalization to complete her antibiotic
course; she was told to resume her home diuretic regimen and plan
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psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
January 01, 2021 - Using failure mode and effects analysis to plan implementation of smart i.v. pump technology.
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psnet.ahrq.gov/web-mm/wrongful-resuscitation
October 12, 2012 - that the treating team at the hospital has all the information needed to ensure continuity of the care plan … Third, working with the nursing home staff, the physician formulates a care plan that ensures that those … this includes a referral to hospice that will work with the staff in the nursing home to formulate a plan … patient is in living with multiple chronic illnesses, formulates goals of care, and then develops a plan … Key parts of this plan include taking steps to ensure that the goals of care are communicated across
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psnet.ahrq.gov/node/37332/psn-pdf
November 14, 2007 - help organizations identify health literacy issues, as well
as methods for implementing an action plan
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psnet.ahrq.gov/node/44909/psn-pdf
March 23, 2016 - cause analysis can be applied to community pharmacy services to identify problems
and design an action plan
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psnet.ahrq.gov/node/43549/psn-pdf
September 27, 2016 - resident-resident-handoffs-emergency-department-observational-study
According to this study, information regarding the plan
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psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
March 01, 2009 - May I Have Another?—Medication Error
Citation Text:
Wolf MS. May I Have Another?—Medication Error. 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/node/852698/psn-pdf
August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to
Increase Safety and Diagnostic Accuracy Innovation
August 30, 2023
https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-
diagnostic-accuracy
Summary
Addressing diagnostic errors to improve outcomes and patient safety h…
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psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
December 07, 2009 - SPOTLIGHT CASE
No News May Not Be Good News
Citation Text:
Moore CR. No News May Not Be Good News. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/lost-transition
November 17, 2010 - SPOTLIGHT CASE
Lost in Transition
Citation Text:
Beach C. Lost in Transition. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
July 01, 2012 - EMR Entry Error: Not So Benign
Citation Text:
Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?
Citation Text:
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
C…
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psnet.ahrq.gov/web-mm/volume-too-low-and-out
July 01, 2017 - SPOTLIGHT CASE
Volume Too Low: In and Out
Citation Text:
Miller MR. Volume Too Low: In and Out . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X3 XM…
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - SPOTLIGHT CASE
Diagnosing Diagnostic Mistakes
Citation Text:
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google S…
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens
Citation Text:
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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…
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - SPOTLIGHT CASE
Transfer Troubles
Citation Text:
Hains IM. Transfer Troubles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
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psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures
Citation Text:
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - SPOTLIGHT CASE
When the Lytes Go Out: A Case of Inpatient Cardiac Arrest
Citation Text:
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…
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psnet.ahrq.gov/node/49690/psn-pdf
September 01, 2013 - The Pains of Chronic Opioid Usage
September 1, 2013
Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
Case Objectives
Describe the appropriate initial assessment of patients with chronic non-cancer pain.
List the most comm…