-
psnet.ahrq.gov/node/49406/psn-pdf
June 01, 2003 - The Dangerous Detour
June 1, 2003
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dangerous-detour
The Case
Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service
for observation after being placed on a 72-hour hold by…
-
psnet.ahrq.gov/node/33821/psn-pdf
December 01, 2016 - Errors and Near Misses: What Health Care Could Learn
From Aviation
December 1, 2016
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
Perspective
Some of the most urg…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
December 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case December 2004
Discharge Fumbles
Source and Credits
This presentation is based on the Dec. 2004
AHRQ WebM&M Spotlight Case in Hospital Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Alan Forster, M…
-
psnet.ahrq.gov/node/33623/psn-pdf
December 01, 2005 - The Unintended Consequences of Florida Medical
Liability Legislation
December 1, 2005
Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
Perspective
Quality health …
-
psnet.ahrq.gov/node/49574/psn-pdf
November 01, 2008 - A Mid-Summer Fog
November 1, 2008
Braddock CH. A Mid-Summer Fog. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mid-summer-fog
The Case
A 33-year-old woman with type I diabetes mellitus was admitted for symptoms of left flank pain, dysuria,
and emesis, concerning for pyelonephritis. The patient was taking …
-
psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy
August 16, 2023 - Ruptured Heterotopic Pregnancy
Citation Text:
Cedars MI. Ruptured Heterotopic Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
-
psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
September 07, 2019 - Strategies and Approaches for Tracking Improvements in Patient Safety
Citation Text:
Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citat…
-
psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
-
psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only
Spotlight
Delay in Appropriate Diagnosis and
Treatment Leading to Death from
Pulmonary Embolism
Source and Credits
• This presentation is based on the February 2021 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
-
psnet.ahrq.gov/node/841467/psn-pdf
December 14, 2022 - patient safety concerns, it would be a mistake for hospitals to have a general
policy by which they respond
-
psnet.ahrq.gov/node/865655/psn-pdf
April 24, 2024 - Patients respond to automated questions read by a
computer-generated voice.
-
psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - The time spent to read, document, and respond to patient phone calls and messages can be taxing for office
-
psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
November 01, 2005 - time lag—perhaps 30-60 minutes—during which the primary team or physician is given an opportunity to respond
-
psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - Patients respond to automated questions read by a computer-generated voice.
-
psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - The time spent to read, document, and respond to patient phone calls and messages
can be taxing for
-
psnet.ahrq.gov/node/33801/psn-pdf
February 01, 2016 - my new position at the AMA is to make it an organizational best practice to
regularly measure and respond
-
psnet.ahrq.gov/node/33664/psn-pdf
March 01, 2008 - And then, even more importantly, is knowing how to respond when a procedure doesn't go well.
-
psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
August 01, 2005 - It is a continuing puzzle that health care does not respond to economic and research indicators the same
-
psnet.ahrq.gov/node/862983/psn-pdf
February 28, 2024 - Take-Home Points
Anesthesia clinicians need to monitor patients vigilantly so that they can respond
-
psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - to "implement a standardized approach to handoff communications including an opportunity to
ask and respond