-
psnet.ahrq.gov/node/74017/psn-pdf
October 27, 2021 - Ensuring primary care diagnostic quality in the era of
telemedicine.
October 27, 2021
Willis JS, Tyler C, Schiff GD, et al. Ensuring primary care diagnostic quality in the era of telemedicine. Am J
Med. 2021;134(9):1101-1103. doi:10.1016/j.amjmed.2021.04.027.
https://psnet.ahrq.gov/issue/ensuring-primary-care-diag…
-
psnet.ahrq.gov/node/841479/psn-pdf
December 14, 2022 - Fast does not imply flawed: analyzing emergency
physician productivity and medical errors.
December 14, 2022
Hoot NR, Barbosa TJ, Chan HK, et al. Fast does not imply flawed: analyzing emergency physician
productivity and medical errors. J Am Coll Emerg Physicians Open. 2022;3(6):e12849.
doi:10.1002/emp2.12849.
ht…
-
psnet.ahrq.gov/node/73113/psn-pdf
April 07, 2021 - Analysis of results from event investigations in industrial
and patient safety contexts.
April 7, 2021
Harms-Ringdahl L. Analysis of results from event investigations in industrial and patient safety contexts.
Safety. 2021;7(1):19. doi:10.3390/safety7010019.
https://psnet.ahrq.gov/issue/analysis-results-event-inve…
-
psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - Involve experts across the state or region to develop materials and support implementation. … Reports in a format that allows hospitals to track performance against other sites across a state or
region … data collection and reporting methods
Using multidisciplinary experts from throughout the targeted region
-
psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - Syringe Swap During Regional Block: A Case of
Medication Error and Recovery
January 31, 2024
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…
-
psnet.ahrq.gov/node/35186/psn-pdf
July 13, 2005 - Saving lives: hospitals have signed on to a six-part plan
to avoid a multitude of unnecessary deaths.
July 13, 2005
Comarow A. US News & World Report. July 2005
https://psnet.ahrq.gov/issue/saving-lives-hospitals-have-signed-six-part-plan-avoid-multitude-unnecessary-
deaths
This article, accompanying the widely r…
-
psnet.ahrq.gov/node/40897/psn-pdf
November 02, 2011 - Infrequent physician use of implantable cardioverter-
defibrillators risks patient safety.
November 2, 2011
Lyman S, Sedrakyan A, Do H, et al. Infrequent physician use of implantable cardioverter-defibrillators risks
patient safety. Heart. 2011;97(20):1655-60. doi:10.1136/hrt.2011.226282.
https://psnet.ahrq.gov/is…
-
psnet.ahrq.gov/node/46081/psn-pdf
April 19, 2017 - Why are medical errors still a leading cause of death?
April 19, 2017
Headley M.
https://psnet.ahrq.gov/issue/why-are-medical-errors-still-leading-cause-death
This magazine article explores the need for robust research and effective reporting to better understand the
prevalence of medical errors and how to prevent…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
December 01, 2013 - PowerPoint Presentation
Spotlight Case
New Oral Anticoagulants
1
This presentation is based on the December 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Margaret C. Fang, MD, MPH, University of California, San Francisco
Editor, AHRQ WebM&M…
-
psnet.ahrq.gov/node/865924/psn-pdf
May 22, 2024 - Health professionals' experiences of whistleblowing in
maternal and newborn healthcare settings: a scoping
review and thematic analysis.
May 22, 2024
Capper T, Ferguson B, Muurlink O. Health professionals' experiences of whistleblowing in maternal and
newborn healthcare settings: a scoping review and thematic anal…
-
psnet.ahrq.gov/node/863209/psn-pdf
February 28, 2024 - Emergency department volume and delayed diagnosis of
serious pediatric conditions.
February 28, 2024
Michelson KA, Rees CA, Florin TA, et al. Emergency department volume and delayed diagnosis of serious
pediatric conditions. JAMA Pediatr. 2024;178(4):362-368. doi:10.1001/jamapediatrics.2023.6672.
https://psnet.ahr…
-
psnet.ahrq.gov/node/853433/psn-pdf
September 13, 2023 - Outcomes of missed diagnosis of pediatric appendicitis,
new-onset diabetic ketoacidosis, and sepsis in five
pediatric hospitals.
September 13, 2023
Michelson KA, Bachur RG, Grubenhoff JA, et al. Outcomes of missed diagnosis of pediatric appendicitis,
new-onset diabetic ketoacidosis, and sepsis in five pediatric ho…
-
psnet.ahrq.gov/node/42961/psn-pdf
February 19, 2014 - Healthcare-associated infections: a national patient safety
problem and the coordinated response.
February 19, 2014
Jeeva RR, Wright D. Healthcare-associated infections: a national patient safety problem and the
coordinated response. Med Care. 2014;52(2 Suppl 1):S4-8. doi:10.1097/MLR.0b013e3182a54581.
https://psne…
-
psnet.ahrq.gov/node/42751/psn-pdf
November 20, 2013 - What makes maternity teams effective and safe? Lessons
from a series of research on teamwork, leadership and
team training.
November 20, 2013
Siassakos D, Fox R, Bristowe K, et al. What makes maternity teams effective and safe? Lessons from a
series of research on teamwork, leadership and team training. Acta Obste…
-
psnet.ahrq.gov/node/40349/psn-pdf
May 11, 2011 - Use of briefings and debriefings as a tool in improving
team work, efficiency, and communication in the
operating theatre.
May 11, 2011
Bethune R, Sasirekha G, Sahu A, et al. Use of briefings and debriefings as a tool in improving team work,
efficiency, and communication in the operating theatre. Postgrad Med J. 2…
-
psnet.ahrq.gov/node/38904/psn-pdf
September 02, 2009 - Litigation related to inadequate anaesthesia: an analysis
of claims against the NHS in England 1995-2007.
September 2, 2009
Mihai R, Scott SD, Cook TM. Litigation related to inadequate anaesthesia: an analysis of claims against the
NHS in England 1995-2007. Anaesthesia. 2009;64(8):829-35. doi:10.1111/j.1365-2044.20…
-
psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.
Citation Text:
Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
-
psnet.ahrq.gov/node/846768/psn-pdf
March 29, 2023 - Endotracheal Tube Fallout in a Patient with Severe
Obesity During Eye Surgery.
March 29, 2023
Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
The Ca…
-
psnet.ahrq.gov/node/838316/psn-pdf
October 12, 2022 - The Lancet Commission on lessons for the future from
the COVID-19 pandemic.
October 12, 2022
Sachs JD, Karim SSA, Aknin L, et al. The Lancet Commission on lessons for the future from the COVID-19
pandemic. Lancet. 2022;400(10359):1224-1280. doi:10.1016/s0140-6736(22)01585-9.
https://psnet.ahrq.gov/issue/lancet-com…
-
psnet.ahrq.gov/node/50887/psn-pdf
February 12, 2020 - Lessons learned from a systems approach to engaging
patients and families in patient safety transformation.
February 12, 2020
Hatlie MJ, Nahum A, Leonard R, et al. Lessons Learned from a Systems Approach to Engaging Patients
and Families in Patient Safety Transformation. Jt Comm J Qual Patient Saf. 2020;46(3):158-1…