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psnet.ahrq.gov/node/47452/psn-pdf
December 27, 2018 - The preventable proportion of healthcare-associated
infections 2005-2016: systematic review and meta-
analysis.
December 27, 2018
Schreiber PW, Sax H, Wolfensberger A, et al. The preventable proportion of healthcare-associated
infections 2005-2016: Systematic review and meta-analysis. Infect Control Hosp Epidemiol…
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psnet.ahrq.gov/node/45739/psn-pdf
July 02, 2017 - High-risk medications in hospitalized elderly adults: are
we making it easy to do the wrong thing?
July 2, 2017
Blachman NL, Leipzig RM, Mazumdar M, et al. High-Risk Medications in Hospitalized Elderly Adults: Are
We Making It Easy to Do the Wrong Thing? J Am Geriatr Soc. 2017;65(3):603-607. doi:10.1111/jgs.14703.
…
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psnet.ahrq.gov/node/44376/psn-pdf
October 08, 2016 - Avoidability of hospital deaths and association with
hospital-wide mortality ratios: retrospective case record
review and regression analysis.
October 8, 2016
Hogan H, Zipfel R, Neuburger J, et al. Avoidability of hospital deaths and association with hospital-wide
mortality ratios: retrospective case record review…
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psnet.ahrq.gov/node/37096/psn-pdf
June 24, 2010 - Impact of diagnosis-timing indicators on measures of
safety, comorbidity, and case mix groupings from
administrative data sources.
June 24, 2010
Naessens JM, Campbell CR, Berg B, et al. Impact of diagnosis-timing indicators on measures of safety,
comorbidity, and case mix groupings from administrative data sources…
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psnet.ahrq.gov/node/45889/psn-pdf
August 16, 2017 - New persistent opioid use after minor and major surgical
procedures in US adults.
August 16, 2017
Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical
Procedures in US Adults. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/45333/psn-pdf
September 21, 2016 - Association of inpatient hospital experience with patient
safety indicators: a cross-sectional, Canadian study.
September 21, 2016
Kemp KA, Santana MJ, Southern DA, et al. Association of inpatient hospital experience with patient safety
indicators: a cross-sectional, Canadian study. BMJ Open. 2016;6(7):e011242. doi…
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psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
July 08, 2022 - , appropriate leadership (nursing, surgery, anesthesia, medicine, and allergy/immunology) should be represented
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psnet.ahrq.gov/web-mm/urine-tough-position
January 01, 2009 - Urine a Tough Position
Citation Text:
Gandhi TK. Urine a Tough Position. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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psnet.ahrq.gov/node/49631/psn-pdf
July 01, 2011 - Patient Safety and Adherence to Self-Administered
Medications
July 1, 2011
Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications.
PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
The Case
A 30-year-o…
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psnet.ahrq.gov/node/49473/psn-pdf
March 01, 2005 - On O.R. Off?
March 1, 2005
Leonard M. On O.R. Off? PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/or
The Case
An elderly man was admitted to the vascular surgery service with rest pain in his leg. Angiography
demonstrated peripheral artery disease with anatomy suitable for revascularization. A consulting
…
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psnet.ahrq.gov/node/49449/psn-pdf
June 01, 2004 - Lethal Vertigo
June 1, 2004
Furman JM. Lethal Vertigo. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-vertigo
The Case
A 64-year-old woman, with no prior medical history, complained of sudden onset of severe vertigo and
vomiting, without headache. Her initial blood pressure in the emergency departme…
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psnet.ahrq.gov/node/49487/psn-pdf
August 21, 2005 - Surprise Wire
August 21, 2005
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/surprise-wire
The Case
A 39-year-old man with a history of liver disease presented to the emergency department (ED) with
gastrointestinal bleeding and altered mental status. Due to his clinic…
-
psnet.ahrq.gov/node/49395/psn-pdf
April 01, 2003 - Medication Overdose
April 1, 2003
Kaushal R. Medication Overdose. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/medication-overdose
The Case
A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He
was diagnosed with status epilepticus and started on a loading…
-
psnet.ahrq.gov/node/49850/psn-pdf
January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia
January 1, 2019
Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
The Case
A 72-year-old woman with a history of severe peripheral vascular dis…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
September 27, 2023 - Bourgeois, OD, MD, and Glen Xiong, MD This unfortunate case likely represented a presentation of psychotic
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
January 01, 2022 - substitute equivalent non-latex products for latex products, so
administrative leadership should also be represented
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - Given that this case represented a respiratory arrest, as opposed to a cardiac event (given known aspiration
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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - Following publication of the results, the Hospital Ethics and Research Committee determined that this represented
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psnet.ahrq.gov/node/49861/psn-pdf
May 01, 2019 - Updates in the Management of High-Risk Pulmonary
Embolism
May 1, 2019
Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
Case Objectives
Review common risk factors, typical present…
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psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - Deaths Not Foretold: Are Unexpected Deaths Useful
Patient Safety Signals?
December 1, 2007
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
The Case
…