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psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
January 01, 2024 - dependent upon an
elaborate annular and cruciate pulley system that multiplies mechanical forces, reduces
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - communication, and procedure implementation can contribute positively to support an education
program that reduces
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psnet.ahrq.gov/node/33743/psn-pdf
December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing
and Treating Delirium in the Intensive Care Unit
December 1, 2012
Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating
Delirium in the Intensive Care Unit. PSNet [internet]. 2012.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/73953/psn-pdf
October 27, 2021 - Deprescribing as a Patient Safety Strategy
October 27, 2021
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
Background
Polypharmacy is defined as the act of taking five or more medications on a regular basis…
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psnet.ahrq.gov/node/60376/psn-pdf
July 30, 2020 - COVID-19: Team and Human Factors to Improve Safety
July 30, 2020
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
Background
The rapid transmission of COVID-19 has resulted in an international pandem…
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psnet.ahrq.gov/node/49827/psn-pdf
April 01, 2018 - Walking Patient, Missing Drain
April 1, 2018
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/walking-patient-missing-drain
The Case
A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective
…
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psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - Amphotericin Toxicity
October 1, 2015
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/amphotericin-toxicity
The Case
A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral
posaconazole for residual fungal disease. She present…
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psnet.ahrq.gov/node/72624/psn-pdf
January 05, 2021 - The LifePoint National Quality Program Provides
Structured Framework for Reducing Inpatient Harm
January 5, 2021
https://psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-
reducing-inpatient-harm
Summary
Building on the company’s experience as a Hospital Engagement Network…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case March 2007
Failure to Report
Source and Credits
This presentation is based on the March 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrice L. Spath, BA, RHIT, Brown-Sp…
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
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psnet.ahrq.gov/node/49559/psn-pdf
April 01, 2008 - The Forgotten Drip
April 1, 2008
Josephson AS. The Forgotten Drip. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/forgotten-drip
The Case
A 45-year-old man was brought to the emergency department by his friends because of a 1-day history of a
severe headache and "bizarre behavior." A computed tomography (C…
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psnet.ahrq.gov/issue/counting-matters-lessons-root-cause-analysis-retained-surgical-item
January 02, 2017 - Commentary
Counting matters: lessons from the root cause analysis of a retained surgical item.
Citation Text:
Agrawal A. Counting matters: lessons from the root cause analysis of a retained surgical item. Jt Comm J Qual Patient Saf. 2012;38(12):566-574.
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psnet.ahrq.gov/issue/safe-prescribing-educational-intervention-medical-students
September 24, 2010 - Study
Safe prescribing: an educational intervention for medical students.
Citation Text:
Garbutt J, DeFer TM, Highstein G, et al. Safe prescribing: an educational intervention for medical students. Teach Learn Med. 2006;18(3):244-50.
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psnet.ahrq.gov/issue/leaders-role-medical-device-safety
August 14, 2017 - Newspaper/Magazine Article
The leader's role in medical device safety.
Citation Text:
Federico F. The leader's role in medical device safety. Healthcare executives must ensure appropriate policies, procedures. Healthcare executive. 2013;28(3):82-5.
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Format:
G…
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psnet.ahrq.gov/issue/error-blame-and-law-health-care-antipodean-perspective
August 02, 2015 - Commentary
Error, blame, and the law in health care—an antipodean perspective.
Citation Text:
Runciman WB, Merry A, Tito F. Error, blame, and the law in health care--an antipodean perspective. Ann Intern Med. 2003;138(12):974-9.
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psnet.ahrq.gov/issue/provider-implicit-bias-bringing-awareness-clinical-practice
November 30, 2016 - Newspaper/Magazine Article
Provider implicit bias: bringing awareness to clinical practice.
Citation Text:
Provider implicit bias: bringing awareness to clinical practice. Moss LD. Clinical Advisor. June 29, 2022.
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psnet.ahrq.gov/issue/special-k-no-license-kill-accidental-ketamine-overdose-induction-general-anesthesia
March 17, 2021 - Commentary
Special K with no license to kill: accidental ketamine overdose on induction of general anesthesia.
Citation Text:
Warner LL, Smischney N. Accidental Ketamine Overdose on Induction of General Anesthesia. Am J Case Rep. 2018;19:10-12.
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psnet.ahrq.gov/issue/organising-manuscript-reporting-quality-improvement-or-patient-safety-research
May 11, 2011 - Commentary
Organising a manuscript reporting quality improvement or patient safety research.
Citation Text:
Holzmueller CG, Pronovost P. Organising a manuscript reporting quality improvement or patient safety research. BMJ Qual Saf. 2013;22(9):777-85. doi:10.1136/bmjqs-2012-001603.
Co…
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psnet.ahrq.gov/issue/verbal-medication-orders-or
March 06, 2024 - Commentary
Verbal medication orders in the OR.
Citation Text:
Hendrickson T. Verbal medication orders in the OR. AORN J. 2007;86(4):626-9.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/10-patient-safety-tips-hospitals
December 09, 2009 - Fact Sheet/FAQs
Classic
10 Patient Safety Tips for Hospitals.
Citation Text:
10 Patient Safety Tips for Hospitals. Rockville, MD: Agency for Healthcare Research and Quality; December 2009. AHRQ Publication No. 10-M008.
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