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2401. Delay in Initiating Antibiotics Results in Fatal Error | PSNet
      psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
      August 02, 2015 - SPOTLIGHT CASE Delay in Initiating Antibiotics Results in Fatal Error Citation Text: Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation …

2402. Webmm Spotlight Suicide Risk Assessment (pdf file)
      psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
      January 01, 2019 - Spotlight Missed Opportunities for Suicide Risk Assessment Source and Credits • This presentation is based on the November 2019 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Glen Xiong, MD & Debra Kahn, MD ○ Editors in Chief, AHRQ We…

2403. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33839/psn-pdf
      August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS August 1, 2017 In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwester…

2404. A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic | PSNet
      psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
      October 30, 2024 - A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL April 27, 2022 Innovation Conta…

2405. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33744/psn-pdf
      February 01, 2013 - In Conversation With… Beverley H. Johnson February 1, 2013 In Conversation With… Beverley H. Johnson. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson Editor's note: Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient- and Family-…

2406. Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
      January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx Spotlight Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities Source and Credits • This presentation is based on the March 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…

2407. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49857/psn-pdf
      March 01, 2019 - Duplicate Insulin Order March 1, 2019 Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/duplicate-insulin-order The Case A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency department (ED) for complaints of letharg…

2408. The Hazards of Distraction: Ticking All the EHR Boxes | PSNet
      psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
      April 09, 2014 - SPOTLIGHT CASE The Hazards of Distraction: Ticking All the EHR Boxes Citation Text: Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation …

2409. Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans | PSNet
      psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
      July 23, 2024 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 31, 2023 Innovation Contact …

2410. Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes) | PSNet
      psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
      February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes) Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

2411. Innovations | PSNet
      psnet.ahrq.gov/innovations
      February 26, 2025 - Innovations The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …

2412. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857259/psn-pdf
      November 30, 2023 - Medication Mix-Up Leads to Patient Death November 30, 2023 Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death The Case  An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…

2413. The Safety Challenges of Supervision and Night Coverage in Academic Residency | PSNet
      psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
      February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency Citation Text: Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…

2414. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-469
      December 31, 2024 - January 8, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports…

2415. In Conversation with... Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring | PSNet
      psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
      March 15, 2023 - (COPD) and congestive heart failure (CHF), resulting in fewer emergency department visits, hospital readmission

2416. Remote Patient Monitoring | PSNet
      psnet.ahrq.gov/perspective/remote-patient-monitoring
      March 15, 2023 - (COPD) and congestive heart failure (CHF), resulting in fewer emergency department visits, hospital readmission

2417. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60066/psn-pdf
      March 25, 2020 - boarding are well established and include negative effects on patients (e.g., increased mortality, readmission

2418. Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care | PSNet
      psnet.ahrq.gov/web-mm/culture-clash-no-more-integration-and-coordination-disease-treatment-and-palliative-care
      December 23, 2020 - April 11, 2011 Effect of a postdischarge virtual ward on readmission or death for high-risk

2419. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care | PSNet
      psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
      November 25, 2020 - boarding are well established and include negative effects on patients (e.g., increased mortality, readmission

2420. Hidden Mystery | PSNet
      psnet.ahrq.gov/web-mm/hidden-mystery
      December 01, 2011 - SPOTLIGHT CASE Hidden Mystery Citation Text: Brunette DD. Hidden Mystery. 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 …