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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
October 01, 2015 - PowerPoint Presentation
Spotlight
The Risks of Absent Interoperability:
Medication-Induced Hemolysis in a Patient With a Known Allergy
1
This presentation is based on the October 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/
CME credit is available
Commentary by: Jacob Reider,…
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psnet.ahrq.gov/issue/navigating-information-technology-highway-computer-solutions-reduce-errors-and-enhance
September 01, 2016 - Review
Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety.
Citation Text:
Koshy R. Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety. Transfusion (Paris). 2005;45(4 Su…
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psnet.ahrq.gov/issue/healthcare-simulation-week
June 08, 2023 - Multi-use Website
Healthcare Simulation Week.
Citation Text:
Healthcare Simulation Week. Society for Simulation in Healthcare.
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psnet.ahrq.gov/node/43959/psn-pdf
September 01, 2016 - Evaluation of an automated surveillance system using
trigger alerts to prevent adverse drug events in the
intensive care unit and general ward.
September 1, 2016
DiPoto JP, Buckley MS, Kane-Gill SL. Evaluation of an automated surveillance system using trigger alerts
to prevent adverse drug events in the intensive …
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psnet.ahrq.gov/node/38837/psn-pdf
June 28, 2011 - A comparison of hospital adverse events identified by
three widely used detection methods.
June 28, 2011
Naessens JM, Campbell CR, Huddleston JM, et al. A comparison of hospital adverse events identified by
three widely used detection methods. Int J Qual Health Care. 2009;21(4):301-7.
doi:10.1093/intqhc/mzp027.
h…
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psnet.ahrq.gov/issue/canadian-patient-safety-week
August 24, 2022 - Multi-use Website
Canadian Patient Safety Week.
Citation Text:
Canadian Patient Safety Week. Healthcare Excellence Canada.
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…
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psnet.ahrq.gov/issue/what-drugs-do-you-take-hospitals-seek-collect-better-data-and-prevent-errors
August 17, 2016 - Newspaper/Magazine Article
What drugs do you take? Hospitals seek to collect better data and prevent errors.
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June 13, 2011
View more…
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psnet.ahrq.gov/issue/council-surgical-and-perioperative-safety
February 08, 2023 - Multi-use Website
Council on Surgical and Perioperative Safety.
Citation Text:
Council on Surgical and Perioperative Safety. 633 N. St. Clair St. Chicago, IL, 60611.
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Facebo…
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psnet.ahrq.gov/issue/ahrq-2008-annual-conference
December 24, 2008 - Government Resource
AHRQ 2008 Annual Conference.
Citation Text:
AHRQ 2008 Annual Conference. Agency for Healthcare Research and Quality; AHRQ.
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psnet.ahrq.gov/issue/ahrq-2009-annual-conference
December 24, 2008 - Meeting/Conference Proceedings
AHRQ 2009 Annual Conference.
Citation Text:
AHRQ 2009 Annual Conference. Agency for Healthcare Research and Quality; AHRQ.
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psnet.ahrq.gov/issue/health-literacy-0
December 24, 2008 - Multi-use Website
Health Literacy.
Citation Text:
Health Literacy. Agency for Healthcare Research and Quality
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…
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psnet.ahrq.gov/node/38465/psn-pdf
March 17, 2011 - Council on Surgical and Perioperative Safety.
March 17, 2011
633 N. St. Clair St. Chicago, IL, 60611.
https://psnet.ahrq.gov/issue/council-surgical-and-perioperative-safety
This Web site provides information about the Council on Surgical and Perioperative Safety, a group
of seven organizations that raises awarenes…
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - Annual Perspective
Annual Perspective: Topics in Medication Safety
March 31, 2022
View more articles from the same authors.
Citation Text:
Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/node/39524/psn-pdf
January 17, 2012 - Computerized medication order errors studied.
January 17, 2012
McGee MK. Information Week. April 28, 2010.
https://psnet.ahrq.gov/issue/computerized-medication-order-errors-studied
This news article details how research on errors related to computerized provider order entry may help
prevent them in the future.
ht…
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psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable
Citation Text:
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. 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 - Urinary Retention Dilemma
November 1, 2006
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma
The Case
Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy
(BPH) and urinary hesitancy returned to th…
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psnet.ahrq.gov/node/49694/psn-pdf
October 01, 2013 - Are You Mrs. A? An Issue of Identification Over
Telephone
October 1, 2013
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
The Case
Mr. A was a 78-year-old man admitted with non-ST elevation…
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Danger in Disruption
October 1, 2009
Fontaine DK. Danger in Disruption. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/danger-disruption
The Case
A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had
metabolic alkalosis (pH = 7.58), and her last peripheral…
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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/node/73515/psn-pdf
August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces
Hospitalizations Among Nursing Home Residents
July 28, 2021
https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-
home-residents
Summary
The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…