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psnet.ahrq.gov/node/36200/psn-pdf
February 15, 2011 - Choosing your words carefully: how physicians would
disclose harmful medical errors to patients.
February 15, 2011
Gallagher TH, Garbutt J, Waterman AD, et al. Choosing your words carefully: how physicians would
disclose harmful medical errors to patients. Arch Intern Med. 2006;166(15):1585-1593.
https://psnet.ahr…
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psnet.ahrq.gov/node/46361/psn-pdf
May 23, 2018 - Inadequate hand-off communication.
May 23, 2018
Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6.
https://psnet.ahrq.gov/issue/inadequate-hand-communication
The Joint Commission publishes sentinel event alerts to draw attention to pressing or emerging safety
issues and provide guidelines fo…
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psnet.ahrq.gov/node/42575/psn-pdf
September 26, 2016 - Are interventions to reduce interruptions and errors
during medication administration effective?: a systematic
review.
September 26, 2016
Raban MZ, Westbrook JI. Are interventions to reduce interruptions and errors during medication
administration effective?: a systematic review. BMJ Qual Saf. 2014;23(5):414-21. d…
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psnet.ahrq.gov/node/60653/psn-pdf
April 25, 2020 - Health Care Delivery and Pharmacists During the COVID-
19 Pandemic
June 29, 2020
Dopp AL, Fitall E, Hall KK, et al. Health Care Delivery and Pharmacists During the COVID-19 Pandemic.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
Medication…
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psnet.ahrq.gov/node/49395/psn-pdf
April 01, 2003 - Medication Overdose
April 1, 2003
Kaushal R. Medication Overdose. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/medication-overdose
The Case
A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He
was diagnosed with status epilepticus and started on a loading…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-indications-notes.docx
April 01, 2022 - Central Venous Catheter Indications Facilitator Notes
CLABSI Module:
Central Venous Catheter Indications and Alternatives
Facilitator Guide
Slide Number and Image
This module, titled “Central Venous Catheter Indications and Alternatives,” is part of the Agency for Healthcare Research and Quality’s Safety Progra…
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www.ahrq.gov/sites/default/files/wysiwyg/topics/impact-opioid-final.pdf
November 01, 2018 - Opioids AHRQ Works: Building Bridges Between Research and Practice
Opioids
Deaths from drug overdoses have risen steadily over the
past 2 decades. The misuse of opioids, such as
prescription pain medications and heroin, has become
widespread across the United States. In response to
dramatic increa…
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psnet.ahrq.gov/node/49826/psn-pdf
April 01, 2018 - Air on the Side of Caution
April 1, 2018
Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/air-side-caution
The Case
A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of
breath and chest pain. A decision was m…
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psnet.ahrq.gov/node/49814/psn-pdf
December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation
Mishap
December 1, 2017
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
The Case
A 63-year-old man with a history of coronary…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
November 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case November 2006
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
Source and Credits
This presentation is based on the November 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
June 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case June 2005
Getting to the Root of the Matter
Source and Credits
This presentation is based on the June 2005
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Scott Flanders, MD; Sa…
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psnet.ahrq.gov/web-mm/discharged-blindly
October 26, 2022 - Discharged Blindly
Citation Text:
Iezzoni LI. Discharged Blindly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Kohl.pdf
April 01, 2004 - However, unlike most drugs, immunizations are
usually given to healthy, young individuals for preventive
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Magid.pdf
January 01, 2004 - Translating Patient Safety Research into Clinical Practice
163
Translating Patient Safety Research
into Clinical Practice
David J. Magid, Paul A. Estabrooks, David W. Brand,
Marsha A. Raebel, Ted E. Palen, John F. Steiner,
Eli J. Korner, David W. Bates, Richard Platt, Russell E. Glasgow
Abstract
There is…
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www.ahrq.gov/hai/tools/mvp/modules/technical/sat-sbt-lit-review.html
January 01, 2017 - Spontaneous Awakening Trials and Spontaneous Breathing Trials Literature Review
AHRQ Safety Program for Mechanically Ventilated Patients
Summary
Spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) reduce the length of mechanical ventilation, thereby reducing the risk for de…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/sat-sbt-litreview.docx
January 01, 2017 - Tool: SSA
Summary
Spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) reduce the length of mechanical ventilation, thereby reducing the risk for developing ventilator-associated pneumonia (VAP). Since the guidelines were written in 2007, a groundbreaking article by Girard in 20081 showed that SA…
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing
Citation Text:
Giannini J, Wong M, Dager W, et al. Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
March 12, 2008 - Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes
Evaluation of Medications Removed from Automated
Dispensing Machines Using the Override Function
Leading to Multiple System Changes
Karla Miller, PharmD; Manisha Shah, MBA, RT; Lau…
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - SNFs: Opening the Black Box
December 1, 2013
Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/snfs-opening-black-box
The Case
An 88-year-old woman was admitted to a skilled nursing facility (SNF) after a lengthy hospitalization for a
small bowel obstructio…
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psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - Signout Fallout
February 1, 2018
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/signout-fallout
Case Objectives
Understand the role of communication failures in medical errors and preventable adverse events.
Review the evidence in support of handoff improvement pr…