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psnet.ahrq.gov/issue/predictors-hospital-postoperative-opioid-overdose-after-major-elective-operations-nationally
March 17, 2021 - Study
Predictors of in-hospital postoperative opioid overdose after major elective operations: a nationally representative cohort study.
Citation Text:
Cauley CE, Anderson G, Haynes AB, et al. Predictors of In-hospital Postoperative Opioid Overdose After Major Elective Operations: A Nati…
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psnet.ahrq.gov/node/35863/psn-pdf
March 18, 2010 - Healthcare industry representatives: maximizing benefits
and reducing risks.
March 18, 2010
PA PSRS Patient Saf Advis 2006 Mar;3(1):13-19.
https://psnet.ahrq.gov/issue/healthcare-industry-representatives-maximizing-benefits-and-reducing-risks
This article addresses strategies for minimizing patient safety risks re…
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - Approach to Improving Safety
36
37
Approach to Improving Safety (1)
• This case represents a classic … Each layer of cheese
represents an independent layer of defense against error as long as
the holes
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - In the Swiss Cheese Model, each “slice” of “cheese”
represents a measure taken to enhance patient safety … Each “moment” represents a point in medication use when actions by the patient or caregiver
can reduce
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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - In the Swiss Cheese Model, each “slice” of “cheese” represents a measure taken to enhance patient safety … Each “moment” represents a point in medication use when actions by the patient or caregiver can reduce
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psnet.ahrq.gov/node/60169/psn-pdf
March 25, 2020 - side effects of intravenous gentamicin therapy, the erroneous intravenous administration
of this drug represents
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psnet.ahrq.gov/node/843736/psn-pdf
February 01, 2023 - Approach to Improving Patient Safety
While the patient in this case ultimately had a good outcome, it represents
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psnet.ahrq.gov/node/33848/psn-pdf
December 01, 2017 - attending then gravely addressed
the assembled surgical attendings and residents:
I think that this case represents
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psnet.ahrq.gov/node/49460/psn-pdf
September 01, 2004 - The Commentary
This case represents a common situation in which a medical student, having noticed an
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psnet.ahrq.gov/issue/prospective-memory-icu-effect-visual-cues-task-execution-representative-simulation
April 24, 2018 - Study
Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation.
Citation Text:
Grundgeiger T, Sanderson PM, Orihuela B, et al. Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Ergo…
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psnet.ahrq.gov/node/41580/psn-pdf
June 10, 2018 - Raising the index of suspicion: red flags that represent
credible threats to patient safety.
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. July 26, 2012;17:1-3.
https://psnet.ahrq.gov/issue/raising-index-suspicion-red-flags-represent-credible-threats-patient-safety
This newsletter article highlig…
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psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
November 16, 2022 - 2 out of 2 blood cultures positive with the same pathogen, even one that is commonly a contaminant, represents
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psnet.ahrq.gov/issue/using-pediatric-trigger-tool-estimate-total-harm-burden-hospital-acquired-conditions
July 03, 2016 - Study
Using a pediatric trigger tool to estimate total harm burden hospital-acquired conditions represent.
Citation Text:
Stockwell DC, Landrigan CP, Schuster MA, et al. Using a Pediatric Trigger Tool to Estimate Total Harm Burden Hospital-acquired Conditions Represent. Pediatr Qual Saf.…
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psnet.ahrq.gov/taxonomy/term/3475
June 09, 2025 - Error
An act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable outcome or significant potential for such an outcome. For instance, ordering a medication for a patient with a documented allergy to that medication would be an act of commission. Failing to pre…
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psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
July 10, 2024 - " because we recognize that these are not measures where we can say that every single flagged event represents
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psnet.ahrq.gov/node/49448/psn-pdf
June 01, 2004 - The Commentary
The case presented represents a near miss.
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psnet.ahrq.gov/node/33846/psn-pdf
November 01, 2017 - Health information technology (IT) represents one of the most important tools providers can employ to
-
psnet.ahrq.gov/node/49442/psn-pdf
May 01, 2004 - The Commentary
This case represents an unfortunate failure to identify tuberculosis (TB) in a young
-
psnet.ahrq.gov/node/33850/psn-pdf
January 01, 2018 - The OpenNotes initiative—which allows patients
to read their clinicians' notes—represents another real
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.149_slideshow.ppt
May 01, 2007 - Phenytoin Levels
90% bound to plasma proteins, primarily albumin
Therapeutic range of 10-20 mcg/mL represents