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psnet.ahrq.gov/node/33781/psn-pdf
March 01, 2015 - In Conversation With… Brian Jarman, PhD
March 1, 2015
In Conversation With… Brian Jarman, PhD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
Editor's note: Sir Brian Jarman is an emeritus professor at Imperial College School of Medicine and a
past president of the Britis…
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psnet.ahrq.gov/primer/reporting-patient-safety-events
March 30, 2022 - Reporting Patient Safety Events
Citation Text:
Reporting Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety
Paul J. Sharek, MD, MPH | May 1, 2012
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Sharek PJ. The Emergence of the Trigger Tool as the …
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psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
May 01, 2012 - In Conversation With…David C. Classen, MD, MS
May 1, 2012
Also Read an Essay
Citation Text:
In Conversation With…David C. Classen, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/perspective/conversation-cindy-brach
December 27, 2019 - In Conversation With... Cindy Brach
December 27, 2019
Also Read the Essay
Citation Text:
In Conversation With.. Cindy Brach. PSNet [internet]. 2019.In Conversation With... Cindy Brach. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/node/837959/psn-pdf
August 31, 2022 - The patient developed generalized urticaria, bronchospasm
requiring high airway pressures to achieve
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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - SPOTLIGHT CASE
Difficult Encounters: A CMO and CNO Respond
Citation Text:
Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
January 01, 2024 - Spotlight
Spotlight
Missed Connection: A Case of Inadequate ECG
Oversight in Cardiac Surgery
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Christian Bohringer, MBBS, …
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psnet.ahrq.gov/node/33728/psn-pdf
May 01, 2012 - In Conversation With…David C. Classen, MD, MS
May 1, 2012
In Conversation With…David C. Classen, MD, MS. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
Editor's note: David C. Classen, MD, MS, is Chief Medical Information Officer for Pascal Metrics and an
Associa…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Implementation of Patient Safety Projects
Curated Library
Foundations
Leading change: why transformation efforts fail.
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
Kotter, a professor at Harvard Business School, outlines the eight stages …
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - This is because the Universal Protocol does not differentiate between types of cases requiring imaging … For example, a change in hospital policy requiring imaging to be present in the operating suite prior
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - For patients requiring intermittent paracentesis for symptom relief, it would also be important to ensure … they are taking diuretic therapy or not requiring an increase in that therapy.
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - are also known as critical values, or more accurately as "alert" values,
since some reflect errors requiring … immediate correction rather than clinical conditions requiring immediate
treatment.
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - However, he rapidly
experienced further respiratory decompensation requiring intubation and mechanical … ventilation, as well as
hemodynamic compromise requiring vasopressor support.
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - hospital course was marked by multiorgan failure, septic shock, and spontaneous bowel
perforation requiring … antibiotics are warranted, rather than relying on evidence-based
criteria), and health care system factors (requiring
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - an interruption.(13) Consequently, inadequate laboratory test result follow-up is a system problem
requiring … Inadequate laboratory test result follow-up is a system problem requiring a system solution.
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - potential for medical errors.( 12 ) In 2005, the Joint Commission issued a National Patient Safety Goal requiring … error described in the present case may have been prevented with the use of a standardized checklist requiring
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - beta-glucuronidase in the newborn intestine and, now lipid soluble again, is reabsorbed into the portal circulation, requiring … isoimmunization, maternal antibody can persist for months, and can continue to cause hemolysis, sometimes requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - Misuse
Eighteen hours after infusion, the patient developed severe bleeding and hemodynamic instability requiring