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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - Fire in the Hole!—An OR Fire
Citation Text:
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac
Arrest
September 30, 2020
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
Disclosure of Relevant Financial Relationships: As a pr…
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psnet.ahrq.gov/node/33672/psn-pdf
September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH
September 1, 2008
In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
Editor's note: Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women's
Hospital and Assi…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
May 01, 2017 - PowerPoint Presentation
Spotlight
Diagnostic Delay in the Emergency Department
1
Source and Credits
This presentation is based on the May 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…
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psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - Are You Mrs. A? An Issue of Identification Over Telephone
Citation Text:
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
…
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psnet.ahrq.gov/node/49470/psn-pdf
December 01, 2004 - Discharge Fumbles
December 1, 2004
Forster AJ. Discharge Fumbles. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/discharge-fumbles
Case Objectives
List the types of adverse events that occur at discharge
Identify the characteristics that identify patients at high risk for errors at discharge
Understand th…
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psnet.ahrq.gov/node/50769/psn-pdf
February 15, 2017 - Cultural Competence and Patient Safety
December 27, 2019
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
Background
Culture can be defined as the “personal identification, language, thoughts, co…
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psnet.ahrq.gov/node/49687/psn-pdf
August 21, 2013 - Emergency Error
August 21, 2013
Symons NRA. Emergency Error. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/emergency-error
Case Objectives
State that emergency surgery is high risk and has high mortality.
Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of
…
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psnet.ahrq.gov/node/60044/psn-pdf
March 16, 2020 - Patient Safety in Medical, Nursing, and Other Clinical
Education
March 16, 2020
Howley LD, Hall KK, Fitall E. Patient Safety in Medical, Nursing, and Other Clinical Education . PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
Background
Despit…
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psnet.ahrq.gov/node/33614/psn-pdf
June 01, 2005 - Interpreting the Patient Safety Literature
June 1, 2005
Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
Perspective
Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…
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psnet.ahrq.gov/node/74830/psn-pdf
June 01, 2022 - for
Placement of Peripherally Inserted Central Catheters
(PICCs) Prevents Unnecessary PICC Use and Reduces
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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - Mixing
fewer drugs together or using a local anesthetic alone for spinal injection reduces the chance
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
September 01, 2011 - Spotlight Case July 2008
Spotlight Case
The Safety and Quality of Long Term Care
*
*
Source and Credits
This presentation is based on the September 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Amy A. Vogelsmeier, PhD, RN, GCNS-BC, Uni…
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psnet.ahrq.gov/perspective/what-makes-good-checklist
October 01, 2010 - What Makes a Good Checklist
Anne Collins McLaughlin, PhD | October 1, 2010
Also Read a Conversation
View more articles from the same authors.
Citation Text:
McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/node/44675/psn-pdf
July 05, 2016 - Why July matters.
July 5, 2016
Petrilli CM, Del Valle J, Chopra V. Why July Matters. Acad Med. 2016;91(7):910-912.
doi:10.1097/ACM.0000000000001196.
https://psnet.ahrq.gov/issue/why-july-matters
Studies have reached conflicting conclusions about whether the "July Effect"—the belief that inpatient
mortality increa…
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psnet.ahrq.gov/node/47798/psn-pdf
February 20, 2019 - Simulation safety first: an imperative.
February 20, 2019
Raemer D, Hannenberg A, Mullen A. Simulation Safety First: An Imperative. Simul Healthc.
2018;13(6):373-375. doi:10.1097/SIH.0000000000000341.
https://psnet.ahrq.gov/issue/simulation-safety-first-imperative
Although simulation training heightens the learnin…
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psnet.ahrq.gov/node/50453/psn-pdf
October 09, 2019 - Effect of a sedation weaning protocol on safety and
medication use among hospitalized children post critical
illness
October 9, 2019
Solodiuk JC, Greco CD, O'Donnell KA, et al. Effect of a Sedation Weaning Protocol on Safety and
Medication Use among Hospitalized Children Post Critical Illness. J Pediatr Nurs. 2019…
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psnet.ahrq.gov/node/72778/psn-pdf
February 24, 2021 - Distractions in the cardiac catheterisation laboratory:
impact for cardiologists and patient safety.
February 24, 2021
Mahadevan K, Cowan E, Kalsi N, et al. Distractions in the cardiac catheterisation laboratory: impact for
cardiologists and patient safety. Open Heart. 2020;7(2). doi:10.1136/openhrt-2020-001260.
h…
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psnet.ahrq.gov/node/47850/psn-pdf
March 27, 2019 - Medicines-related harm in the elderly post-hospital
discharge.
March 27, 2019
Cheong V-L, Tomlinson J, Khan S, et al. Prescriber. 2019;30:29-34.
https://psnet.ahrq.gov/issue/medicines-related-harm-elderly-post-hospital-discharge
Geriatric patients are particularly vulnerable to medication-related harm. This articl…
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psnet.ahrq.gov/node/72763/psn-pdf
February 17, 2021 - Apotex Corp. issues voluntary nationwide recall of
Enoxaparin Sodium Injection, USP due to mislabeling of
syringe barrel measurement markings.
February 17, 2021
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 3. 2021.
https://psnet.ahrq.gov/issue/apotex-corp-issues…