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psnet.ahrq.gov/node/73100/psn-pdf
March 31, 2021 - Public comment period extended for strategies to
improve patient safety: Draft Report to Congress for
Public Comment and Review by the National Academy of
Medicine.
March 31, 2021
Fed Register. 2021;86(51):14752-14753.
https://psnet.ahrq.gov/issue/public-comment-period-extended-strategies-improve-patient-safety-d…
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psnet.ahrq.gov/node/37709/psn-pdf
April 23, 2008 - Inappropriate medication use in the elderly: results from a
quality improvement project in 99 primary care practices.
April 23, 2008
Wessell AM, Nietert PJ, Jenkins RG, et al. Inappropriate medication use in the elderly: Results from a
quality improvement project in 99 primary care practices. Am J Geriatr Pharmacot…
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psnet.ahrq.gov/node/38099/psn-pdf
October 01, 2008 - Decreased bile duct injury rate during laparoscopic
cholecystectomy in the era of the 80-hour resident
workweek.
October 1, 2008
Yaghoubian A, Saltmarsh G, Rosing DK, et al. Decreased bile duct injury rate during laparoscopic
cholecystectomy in the era of the 80-hour resident workweek. Arch Surg. 2008;143(9):847-5…
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psnet.ahrq.gov/node/852803/psn-pdf
August 23, 2023 - Sentinel Event Alert 67: Preserving Patient Safety After a
Cyberattack.
August 23, 2023
Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. Jt Comm J Qual Patient Saf.
2023;49(12):724-729. doi:10.1016/j.jcjq.2023.07.006.
https://psnet.ahrq.gov/issue/sentinel-event-alert-67-preserving-patient-sa…
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psnet.ahrq.gov/node/74070/psn-pdf
November 10, 2021 - ERs are swamped with seriously ill patients, although
many don’t have Covid.
November 10, 2021
Wells K. Health Shots. National Public Radio. October 29, 2021.
https://psnet.ahrq.gov/issue/ers-are-swamped-seriously-ill-patients-although-many-dont-have-covid
Emergency department (ED) crowding stemming from treatment…
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psnet.ahrq.gov/node/45866/psn-pdf
March 08, 2017 - Medication safety in the neonatal intensive care unit: big
measures for our smallest patients.
March 8, 2017
Rostas SE. Medication Safety in the Neonatal Intensive Care Unit: Big Measures for Our Smallest Patients.
J Perinat Neonatal Nurs. 2017;31(1):15-19. doi:10.1097/JPN.0000000000000230.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/47129/psn-pdf
September 05, 2018 - Impact of medication reconciliation for improving
transitions of care.
September 5, 2018
Redmond P, Grimes TC, McDonnell R, et al. Impact of medication reconciliation for improving transitions of
care. Cochrane Database Syst Rev. 2018;8(8):CD010791. doi:10.1002/14651858.CD010791.pub2.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/46763/psn-pdf
January 27, 2019 - Human-simulation-based learning to prevent medication
error: a systematic review.
January 27, 2019
Sarfati L, Ranchon F, Vantard N, et al. Human-simulation-based learning to prevent medication error: A
systematic review. J Eval Clin Pract. 2019;25(1):11-20. doi:10.1111/jep.12883.
https://psnet.ahrq.gov/issue/human…
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psnet.ahrq.gov/node/865974/psn-pdf
May 29, 2024 - Minimizing bias when using artificial intelligence in
critical care medicine.
May 29, 2024
Ranard BL, Park S, Jia Y, et al. Minimizing bias when using artificial intelligence in critical care medicine. J
Crit Care. 2024;82:154796. doi:10.1016/j.jcrc.2024.154796.
https://psnet.ahrq.gov/issue/minimizing-bias-when-us…
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psnet.ahrq.gov/node/48005/psn-pdf
May 08, 2019 - Why your doctor's white coat can be a threat to your
health.
May 8, 2019
Haun N, Hooper-Lane C, Safdar N. Healthcare Personnel Attire and Devices as Fomites: A Systematic
Review. Infect Control Hosp Epidemiol. 2016;37(11):1367-1373.
https://psnet.ahrq.gov/issue/why-your-doctors-white-coat-can-be-threat-your-health…
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psnet.ahrq.gov/node/73966/psn-pdf
October 13, 2021 - Prescribing errors with low-molecular-weight heparins.
October 13, 2021
Slikkerveer M, van de Plas A, Driessen JHM, et al. Prescribing errors with low-molecular-weight heparins. J
Patient Saf. 2021;17(7):e587-e592. doi:10.1097/pts.0000000000000417.
https://psnet.ahrq.gov/issue/prescribing-errors-low-molecular-weigh…
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psnet.ahrq.gov/node/46205/psn-pdf
September 20, 2017 - The impact of checklists on inpatient safety outcomes: a
systematic review of randomized controlled trials.
September 20, 2017
Boyd J, Wu G, Stelfox HT. The Impact of Checklists on Inpatient Safety Outcomes: A Systematic Review of
Randomized Controlled Trials. J Hosp Med. 2017;12(8):675-682. doi:10.12788/jhm.2788.
…
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psnet.ahrq.gov/web-mm/beeline-spine
March 01, 2014 - SPOTLIGHT CASE
Beeline to Spine
Citation Text:
Smetana GW. Beeline to Spine. 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 Endno…
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psnet.ahrq.gov/node/73128/psn-pdf
July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions,
and Complications and Enhances Satisfaction for Elderly
Patients.
April 7, 2021
https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-
and-enhances
Summary
The Hospital at Homesm program provides hospital-level care…
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNot…
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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/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/chemotherapy-extravasation
September 24, 2010 - Chemotherapy Extravasation
Citation Text:
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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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/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…