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psnet.ahrq.gov/node/854258/psn-pdf
October 04, 2023 - A virtual breakthrough series collaborative to support
deprescribing interventions across Veterans Affairs
healthcare settings.
October 4, 2023
Phillips KK, Mecca MC, Baim?Lance AM, et al. A virtual breakthrough series collaborative to support
deprescribing interventions across Veterans Affairs healthcare settings…
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psnet.ahrq.gov/node/39249/psn-pdf
September 30, 2015 - Patient participation: current knowledge and applicability
to patient safety.
September 30, 2015
Longtin Y, Sax H, Leape L, et al. Patient participation: current knowledge and applicability to patient safety.
Mayo Clin Proc. 2010;85(1):53-62. doi:10.4065/mcp.2009.0248.
https://psnet.ahrq.gov/issue/patient-particip…
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psnet.ahrq.gov/node/837797/psn-pdf
August 10, 2022 - Toward constructive change after making a medical error:
recovery from situations of error theory as a psychosocial
model for clinician recovery.
August 10, 2022
Harrison R, Johnson J, Mcmullan RD, et al. Toward constructive change after making a medical error:
recovery from situations of error theory as a psychos…
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psnet.ahrq.gov/node/50792/psn-pdf
January 15, 2020 - Lessons learned implementing a complex and innovative
patient safety learning laboratory project in a large
academic medical center
January 15, 2020
Businger AC, Fuller TE, Schnipper JL, et al. Lessons learned implementing a complex and innovative
patient safety learning laboratory project in a large academic medi…
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psnet.ahrq.gov/node/36315/psn-pdf
July 10, 2008 - Wrong-side/wrong-site, wrong-procedure, and wrong-
patient adverse events: are they preventable?
July 10, 2008
Seiden SC, Barach P. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: Are
they preventable? Arch Surg. 2006;141(9):931-9.
https://psnet.ahrq.gov/issue/wrong-sidewrong-site-wrong-p…
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psnet.ahrq.gov/node/45648/psn-pdf
February 01, 2017 - Findings of a naloxone database and its utilization to
improve safety and education in a tertiary care medical
center.
February 1, 2017
Rosenfeld DM, Betcher JA, Shah RA, et al. Findings of a Naloxone Database and its Utilization to Improve
Safety and Education in a Tertiary Care Medical Center. Pain Pract. 2016;1…
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psnet.ahrq.gov/node/866159/psn-pdf
June 19, 2024 - Stakeholder perspectives on contributors to delayed and
inaccurate diagnosis of cardiovascular disease and their
implications for digital health technologies: a UK-based
qualitative study.
June 19, 2024
Abdullayev K, Gorvett O, Sochiera A, et al. Stakeholder perspectives on contributors to delayed and
inaccurate …
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psnet.ahrq.gov/node/866900/psn-pdf
October 09, 2024 - Defects in value associated with hospital-acquired
conditions: how improving quality could save U.S.
healthcare $50 billion.
October 9, 2024
Padula WV, Pronovost PJ. Defects in value associated with hospital-acquired conditions: how improving
quality could save U.S. healthcare $50 billion. J Patient Saf. 2024;20(7…
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Intraoperative Awareness during Rhinoplasty
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Christian Bohringer MBBS and Jaijeet Toor MD
AHRQ WebM&M Edit…
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psnet.ahrq.gov/node/49537/psn-pdf
June 01, 2007 - Beeline to Spine
June 1, 2007
Smetana GW. Beeline to Spine. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/beeline-spine
Case Objectives
Understand the elements of preoperative medical evaluation.
Appreciate the limited role for preoperative laboratory testing.
Appreciate the importance of communication a…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
March 27, 2024 - Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health
Save
Save to your library
Print
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…
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - SPOTLIGHT CASE
A Fatal Twist in Pseudohyperkalemia
Citation Text:
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
…
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy
Citation Text:
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - SPOTLIGHT CASE
Elopement
Citation Text:
Gerardi D. Elopement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - SPOTLIGHT CASE
A Painful Medication Reconciliation Mishap
Citation Text:
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google S…
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psnet.ahrq.gov/node/49675/psn-pdf
February 01, 2013 - Delay in Treatment: Failure to Contact Patient Leads to
Significant Complications
February 1, 2013
Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet
[internet]. 2013.
https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complicat…
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/node/863308/psn-pdf
February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in
Death During Endoscopy
February 28, 2024
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
The Case
A…
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …