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psnet.ahrq.gov/issue/my-five-moments-hand-hygiene-user-centred-design-approach-understand-train-monitor-and-report
September 09, 2020 - Commentary
'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene.
Citation Text:
Sax H, Allegranzi B, Uçkay I, et al. 'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and …
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psnet.ahrq.gov/issue/medication-misadventures-resulting-emergency-department-visits-hmo-medical-center
March 16, 2022 - Study
Classic
Medication misadventures resulting in emergency department visits at an HMO medical center.
Citation Text:
Medication misadventures resulting in emergency department visits at an HMO medical center. Schneitman-McIntire O, Farnen TA, Gordon N, et al…
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psnet.ahrq.gov/issue/failure-rescue-following-emergency-surgery-fram-analysis-management-deteriorating-patient
May 19, 2021 - Study
Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient.
Citation Text:
Sujan M, Bilbro N, Ross A, et al. Failure to rescue following emergency surgery: A FRAM analysis of the management of the deteriorating patient. Appl Ergon.…
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psnet.ahrq.gov/issue/utilization-role-based-head-covering-system-decrease-misidentification-operating-room
September 23, 2020 - Study
Utilization of a role-based head covering system to decrease misidentification in the operating room.
Citation Text:
Rosen DA, Criser AL, Petrone AB, et al. Utilization of a Role-Based Head Covering System to Decrease Misidentification in the Operating Room. J Patient Saf. 2019;15(…
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psnet.ahrq.gov/issue/impact-fatigue-and-insufficient-sleep-physician-and-patient-outcomes-systematic-review
October 19, 2022 - Review
Emerging Classic
Impact of fatigue and insufficient sleep on physician and patient outcomes: a systematic review.
Citation Text:
Gates M, Wingert A, Featherstone R, et al. Impact of fatigue and insufficient sleep on physician and patient outcomes: a syste…
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psnet.ahrq.gov/issue/effect-rapid-response-system-patients-shock-time-treatment-and-mortality-during-5-years
October 19, 2022 - Study
Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years.
Citation Text:
Sebat F, Musthafa AA, Johnson D, et al. Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years. Crit Care M…
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psnet.ahrq.gov/issue/five-year-audit-adherence-anaesthesia-pre-induction-checklist
May 19, 2021 - Study
Five-year audit of adherence to an anaesthesia pre-induction checklist.
Citation Text:
Fuchs A, Frick S, Huber M, et al. Five‐year audit of adherence to an anaesthesia pre‐induction checklist. Anaesthesia. 2022;77(7):751-762. doi:10.1111/anae.15704.
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psnet.ahrq.gov/issue/development-and-performance-evaluation-medicines-optimisation-assessment-tool-moat-prognostic
March 18, 2020 - Study
Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems.
Citation Text:
Geeson C, Wei L, Franklin BD. Development and performance evaluation of the M…
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psnet.ahrq.gov/issue/influence-surgeon-behavior-trainee-willingness-speak-randomized-controlled-trial
February 22, 2019 - Study
Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial.
Citation Text:
Salazar MJB, Minkoff H, Bayya J, et al. Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. J Am Coll Surg. 2014;219(5):1001-…
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psnet.ahrq.gov/issue/prevalence-and-predictors-delayed-clinical-diagnosis-type-2-diabetes-longitudinal-cohort
August 04, 2021 - Study
Prevalence and predictors of delayed clinical diagnosis of Type 2 diabetes: a longitudinal cohort study.
Citation Text:
Gopalan A, Mishra P, Alexeeff SE, et al. Prevalence and predictors of delayed clinical diagnosis of Type 2 diabetes: a longitudinal cohort study. Diabet Med. 2018…
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psnet.ahrq.gov/issue/racialethnic-inequities-pregnancy-related-morbidity-and-mortality
August 10, 2022 - Commentary
Emerging Classic
Racial/ethnic inequities in pregnancy-related morbidity and mortality.
Citation Text:
Minehart RD, Bryant AS, Jackson J, et al. Racial/ethnic inequities in pregnancy-related morbidity and mortality. Obstet Gynecol Clin North Am. 2021;…
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psnet.ahrq.gov/issue/multi-professional-simulation-based-team-training-obstetric-emergencies-improving-patient
July 29, 2020 - Review
Emerging Classic
Multi-professional simulation-based team training in obstetric emergencies for improving patient outcomes and trainees' performance
Citation Text:
Fransen AF, van de Ven J, Banga FR, et al. Multi-professional simulation-based team trainin…
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psnet.ahrq.gov/issue/using-potentially-preventable-severe-maternal-morbidity-monitor-hospital-performance
February 02, 2022 - Study
Using potentially preventable severe maternal morbidity to monitor hospital performance.
Citation Text:
Fridman M, Korst LM, Reynen DJ, et al. Using potentially preventable severe maternal morbidity to monitor hospital performance. Jt Comm J Qual Patient Saf. 2023;49(3):129-137. do…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.170_slideshow.ppt
March 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case March 2008
Back Again
Source and Credits
This presentation is based on the March 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jon D. Lurie, MD, MS
Dartmouth Medical School
Editor, AHRQ WebM…
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psnet.ahrq.gov/node/49816/psn-pdf
January 01, 2018 - A Painful Medication Reconciliation Mishap
January 1, 2018
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
Case Objectives
Recognize that substance use disorders are common in patients with acute pain.
Understand th…
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psnet.ahrq.gov/node/33663/psn-pdf
September 15, 2008 - Implementing a Patient Safety Program at a Large
National Health System
January 1, 2008
Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
Perspectiv…
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psnet.ahrq.gov/issue/healthcare-associated-infections-national-patient-safety-problem-and-coordinated-response
May 20, 2016 - Commentary
Healthcare-associated infections: a national patient safety problem and the coordinated response.
Citation Text:
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:10.109…
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psnet.ahrq.gov/issue/emergency-department-crowding-and-risk-preventable-medical-errors
November 23, 2011 - Study
Emergency department crowding and risk of preventable medical errors.
Citation Text:
Epstein SK, Huckins DS, Liu SW, et al. Emergency department crowding and risk of preventable medical errors. Intern Emerg Med. 2012;7(2):173-180. doi:10.1007/s11739-011-0702-8.
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psnet.ahrq.gov/issue/medication-errors-hospitals-literature-review-disruptions-nursing-practice-during-medication
August 26, 2015 - Review
Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration.
Citation Text:
Hayes C, Jackson D, Davidson PM, et al. Medication errors in hospitals: a literature review of disruptions to nursing practice during medication …
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psnet.ahrq.gov/issue/survival-hospital-cardiac-arrest-during-nights-and-weekends
February 18, 2011 - Study
Survival from in-hospital cardiac arrest during nights and weekends.
Citation Text:
Peberdy MA, Ornato JP, Larkin L, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299(7):785-92. doi:10.1001/jama.299.7.785.
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