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psnet.ahrq.gov/node/49656/psn-pdf
June 01, 2012 - Some
questions to address in the agreement include:
Who is responsible for identifying patients to … The
surgeon and medicine physician should determine whom nurses would call when they have specific
questions
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psnet.ahrq.gov/node/33756/psn-pdf
October 01, 2013 - repetitive protocols are necessary and
have enabled CT to answer a more diverse range of clinical questions … The absence of good data for most
clinical questions has led to overimaging for many years, and that's … Unfortunately, the evidence that can guide imaging is in short supply and, for
most clinical questions
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psnet.ahrq.gov/node/35780/psn-pdf
July 20, 2010 - Paramedic intubation errors: isolated events or
symptoms of larger problems?
July 20, 2010
Wang HE, Lave J, Sirio CA, et al. Paramedic intubation errors: isolated events or symptoms of larger
problems? Health Aff (Millwood). 2006;25(2):501-9.
https://psnet.ahrq.gov/issue/paramedic-intubation-errors-isolated-events…
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psnet.ahrq.gov/node/43435/psn-pdf
August 06, 2014 - Trail of medical missteps in a Peace Corps death.
August 6, 2014
Stolberg SG.
https://psnet.ahrq.gov/issue/trail-medical-missteps-peace-corps-death
Raising concerns about health care provided by the Peace Corps, this newspaper article outlines an
investigation into failures, such as cognitive biases and poor judgm…
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psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
March 01, 2013 - as we can, but at the same time, we have to recognize that we may never know the answer to certain questions … I will discuss the results in relation to four key questions.
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psnet.ahrq.gov/node/41817/psn-pdf
November 07, 2012 - The economic burden of patient safety targets in acute
care: a systematic review.
November 7, 2012
Mittmann N, Matlow A. The economic burden of patient safety targets in acute care: a systematic review.
Drug Healthc Patient Saf. 2012. doi:10.2147/dhps.s33288.
https://psnet.ahrq.gov/issue/economic-burden-patient-sa…
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psnet.ahrq.gov/node/41871/psn-pdf
December 19, 2012 - Certain uncertainties: modes of patient safety in
healthcare.
December 19, 2012
Jerak-Zuiderent S. Certain uncertainties: modes of patient safety in healthcare. Soc Stud Sci.
2012;42(5):732-52.
https://psnet.ahrq.gov/issue/certain-uncertainties-modes-patient-safety-healthcare
Questioning the wisdom of focusing on…
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psnet.ahrq.gov/node/43089/psn-pdf
April 02, 2014 - Save a brain, make a checklist.
April 2, 2014
Hamblin J. The Atlantic. March 17, 2014.
https://psnet.ahrq.gov/issue/save-brain-make-checklist
Reporting on the use of checklists, this magazine article describes studies that identified benefits, such as
reduced complication rates, along with research that questioned…
-
psnet.ahrq.gov/node/43675/psn-pdf
April 18, 2016 - Patient Safety 2015: Final Technical Report.
April 18, 2016
Washington, DC: National Quality Forum; 2016.
https://psnet.ahrq.gov/issue/patient-safety-2015-final-technical-report
The value of current measures to track patient safety has been called into question. This technical report
provides information about a c…
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psnet.ahrq.gov/node/41058/psn-pdf
September 20, 2012 - Medical reconciliation in patients discharged from the
emergency department.
September 20, 2012
Sharma AN, Dvorkin R, Tucker V, et al. Medical reconciliation in patients discharged from the
emergency department. J Emerg Med. 2012;43(2):366-73. doi:10.1016/j.jemermed.2011.05.080.
https://psnet.ahrq.gov/issue/medica…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
November 01, 2003 - Spotlight Case [MONTH] 2003
Spotlight Case November 2003
The Missing Suction Tip
Source and Credits
This presentation is based on the Nov. 2003
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Eric J. Thomas, MD,…
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …
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psnet.ahrq.gov/issue/how-dangerous-day-hospital-model-adverse-events-and-length-stay-medical-inpatients
February 09, 2012 - Study
Classic
How dangerous is a day in hospital?: A model of adverse events and length of stay for medical inpatients.
Citation Text:
Hauck K, Zhao X. How dangerous is a day in hospital? A model of adverse events and length of stay for medical inpatients. Med…
-
psnet.ahrq.gov/node/41744/psn-pdf
November 27, 2012 - Venous thromboembolism after trauma: a never event?
November 27, 2012
Thorson CM, Ryan ML, Van Haren RM, et al. Venous thromboembolism after trauma: a never event?*. Crit
Care Med. 2012;40(11):2967-73. doi:10.1097/CCM.0b013e31825bcb60.
https://psnet.ahrq.gov/issue/venous-thromboembolism-after-trauma-never-event
A …
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psnet.ahrq.gov/node/43513/psn-pdf
September 10, 2014 - Preventing medical errors: how to proceed with caution.
September 10, 2014
Shaw G. Preventing Medical Errors. The Hearing Journal. 2014;67(7).
doi:10.1097/01.hj.0000452244.07451.64.
https://psnet.ahrq.gov/issue/preventing-medical-errors-how-proceed-caution
This article provides an overview of patient safety issues…
-
psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - Or did he raise
ambiguous questions like, "Has anyone seen the catheter tip?"
-
psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - Wyatt, again, showed how three questions arise in almost every clinical encounterand sadly, two out … Yes, we might use a set of digital questionnaires to help us ask all the right questions, but finally … If a digital resource answers questions more quickly in their workflow, they're much more interested
-
psnet.ahrq.gov/node/42516/psn-pdf
February 04, 2016 - "Excuse me": teaching interns to speak up.
February 4, 2016
O'Connor P, Byrne D, O'Dea A, et al. "Excuse me:" teaching interns to speak up. Jt Comm J Qual Patient
Saf. 2013;39(9):426-431.
https://psnet.ahrq.gov/issue/excuse-me-teaching-interns-speak
Previous research has shown that junior physicians may be unwilli…
-
psnet.ahrq.gov/node/36147/psn-pdf
January 13, 2012 - An experimental study in nurse-physician relationships.
January 13, 2012
Hofling CK, Brotzman E, Dalrymple S, et al. An experimental study in nurse-physician relationships. J Nerv
Ment Dis. 1966;143(2):171-80.
https://psnet.ahrq.gov/issue/experimental-study-nurse-physician-relationships
The investigators arranged …
-
psnet.ahrq.gov/node/46857/psn-pdf
May 16, 2018 - The best medical care in the world.
May 16, 2018
Reilly BM. The Best Medical Care in the World. N Engl J Med. 2018;378(18):1741-1743.
doi:10.1056/NEJMms1802026.
https://psnet.ahrq.gov/issue/best-medical-care-world
Patients with serious psychiatric disorders are vulnerable to problems with their care. This commenta…