- 
                                        
psnet.ahrq.gov/node/49734/psn-pdf
May 01, 2015 - (3) Procedural-associated order
sets—electronic or otherwise—might help facilitate by allowing for rapid
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/49739/psn-pdf
August 21, 2015 - Breathe Easy: Safe Tracheostomy Management
August 21, 2015
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
The Case
A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/49691/psn-pdf
September 01, 2013 - DRESSed for Failure
September 1, 2013
Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/dressed-failure
The Case
A 60-year-old woman who uses a wheelchair presented to the emergency department (ED) with right hand
cellulitis and an uncomplicated urinary tract infec… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/33695/psn-pdf
April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest
for Transparency in U.S. Hospitals' Patient Safety
Performance
April 1, 2010
Roberts LL, Ward MM, Evans TC. The Role of the National Quality Forum (NQF) in the Quest for
Transparency in U.S. Hospitals' Patient Safety Performance. PSNet [internet]. 2010.
ht… 
                                     
                                                                    - 
                                        
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… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-intermittent-episodes-dizziness-and-headache
February 08, 2023 - and the patient’s response drove the differential diagnosis and testing (see  Table 1 ). Table 1. … Acute Dizziness Syndrome Description Benign causes a Serious causes a Acute vestibular b  syndrome Rapid … used liberally in patients with intermittent dizziness to elicit the physical finding of nystagmus (rapid
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/33793/psn-pdf
November 01, 2015 - accreditation standard or some other widely recommended intervention like
with medication reconciliation, rapid … response teams, central line bundles, and so on—then of course
there's a role for a trial if it's an
                                     
                                                                    - 
                                        
psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
October 30, 2024 - Managing ICU surge during the COVID-19 crisis: rapid guidelines. … June 21, 2023 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Patient Safety Innovations 
 
 
 
 
 
 
 
 
 Remote Response
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
October 01, 2007 - How would you clarify what the organizational response will be to each type of behavior? … But is a punitive response appropriate for reckless behavior? Our answer is yes. … I think we're seeing from health care regulators and hospitals a pretty rapid movement to find that center
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
December 01, 2014 - nervous just weeks into my new position as the lead for APPS at WHO—I wondered how we would shape our response … Now, 6 years later, we can look back at this response and appreciate some of the lessons that have emerged … thinking in global health, we decided that co-development was absolutely essential.( 7 ) Following a rapid
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/pregnant-danger
January 12, 2011 - circumstances, such as presentation with leg pain, the expertise of the emergency physician and the rapid
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/49648/psn-pdf
March 01, 2012 - Postdischarge Follow-Up Phone Call
March 1, 2012
Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
Case Objectives
Understand why preventing readmissions through postdischarge phone calls is important.
Describe evidence su… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/33843/psn-pdf
October 01, 2017 - In Conversation With… Jeffrey Starke, MD
October 1, 2017
In Conversation With… Jeffrey Starke, MD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-jeffrey-starke-md
Editor's note:  Dr. Starke is Professor of Pediatrics–Infectious Disease at Baylor College of Medicine and
served as Infection… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
December 01, 2014 - nervous just weeks into my new position as the lead for APPS at WHO—I wondered how we would shape our response … Now, 6 years later, we can look back at this response and appreciate some of the lessons that have emerged … thinking in global health, we decided that co-development was absolutely essential.( 7 ) Following a rapid
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - to grow and to help change the culture more than anything.Finally, I've been very encouraged by the response … The response of our hospitals was not at all one of resistance; it was "How do we do it?" … Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid
                                     
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psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice
November 01, 2012 - Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin … RW : In some ways you're swimming against a very rapid stream. … February 1, 2007 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 WebM&M Cases 
 
 
 
 
 
 
 
 
 
 Rapid Mis-St(r)ep
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - Each alarm has a different setting, and the appropriate response to one may be incredibly dangerous for … RW:  We're beginning to see rapid acceleration in electronic records and computerized order entry.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid … December 14, 2022 
 
 
 
 
 
 
 
 
 
 
 Intraoperative code blue: improving teamwork and code response
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/equity-patient-safety
September 24, 2024 - Noting the rapid expansion of telehealth during the COVID-19 pandemic, but also the lack of forward planning … July 31, 2023 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Patient Safety Innovations 
 
 
 
 
 
 
 
 
 Remote Response
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/837959/psn-pdf
August 31, 2022 - The patient was stable after rapid
sequence intubation and maintenance of anesthesia with methohexital