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  1. The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications | PSNet

    psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
    July 23, 2024 - There was a range of use of ID physicians across sites. … Based on the work of the consortium, to implement ID physician approval of PICC placement, sites should … to collect standardized local data Access to data from other participating (and non-participating) sites … https://mi-hms.org/sites/default/files/WISE_040716_FINAL.pdf   HMS PICC toolkit. HMS. … https://mi-hms.org/sites/default/files/WISE_040716_FINAL.pdf TAP central line-associated bloodstream

  2. Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: a case example of patient quality and safety interventions in the ICU. | PSNet

    psnet.ahrq.gov/issue/adapting-rapid-assessment-procedures-implementation-research-using-team-based-approach
    November 09, 2022 - field guides and analytic tools, using a multidisciplinary evaluation team, building trust with the sites … , engaging sites in participatory data collection, rapid team analysis of data sources, and validating … findings with the sites.

  3. Spotlight

    psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
    January 01, 2025 - Spotlight Spotlight Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations  1 Source and Credits This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Samantha Brown…

  4. Spotlight (pdf file)

    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, …

  5. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
    January 01, 2022 - resuscitation • List the indications and contraindications for IO placement • Describe the commonly used sites … previously placed or attempted should not be reattempted because fluids may extravasate from these sites … . – The proximal tibia is easily accessible in most patients and has an advantage over upper body sites … – One animal study compared infusion rates from various IO sites to a peripheral IV site utilizing … , such as the radius, ulna, and fibula, are not suitable sites for IO infusion. 21 Background (12

  6. Assessing the National Electronic Injury Surveillance System—Cooperative Adverse Drug Event Surveillance Project—six sites, United States, January 1–June 15, 2004. | PSNet

    psnet.ahrq.gov/issue/assessing-national-electronic-injury-surveillance-system-cooperative-adverse-drug-event
    February 27, 2019 - National Electronic Injury Surveillance System—Cooperative Adverse Drug Event Surveillance Project—six sites … National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project--six sites … National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project--six sites

  7. Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx Spotlight When the Indications for Drug Administration Blur Source and Credits • This presentation is based on the June 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Julia Munsch,…

  8. Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx Spotlight Premature Closure: Was it Just Syncope? Source and Credits • This presentation is based on the November 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit i…

  9. Spotlight

    psnet.ahrq.gov/sites/default/files/2020-05/webmm.ahrq_.gov_.392_slideshow.pptx
    January 01, 2020 - Spotlight Spotlight Suicidal Ideation in the Family Medicine Clinic 1 Source and Credits This presentation is based on the December 2016 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Christine Moutier, MD, Chief Medical Officer, American …

  10. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-05/final_cme_reviewed_-_spotlight_missing_a_large_vessel_occlusion_stroke_04.14.2022_-_copy.pdf
    January 01, 2022 - Spotlight Spotlight Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures Source and Credits • This presentation is based on the May 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Kevin Keenan, MD and D…

  11. Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
    January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx Spotlight A Loss of Trust and a Missed Diagnosis Source and Credits • This presentation is based on the February 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.…

  12. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
    January 01, 2023 - Spotlight Spotlight Prolonged DKA in Pregnancy: A Case of Communication Breakdown Source and Credits • This presentation is based on the August 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Sarah Marshall, MD and Nina M. …

  13. Randomized trial of reducing ambulatory malpractice and safety risk: results of the Massachusetts PROMISES Project. | PSNet

    psnet.ahrq.gov/issue/randomized-trial-reducing-ambulatory-malpractice-and-safety-risk-results-massachusetts
    February 25, 2015 - Also, time between test date and treatment plan was shorter in intervention sites. … safety improved modestly for coordination and communication but were otherwise similar between the sites … Staff perceptions of safety and quality were similar pre–post and between intervention and control sites

  14. Patient safety culture improves during an in situ simulation intervention: a repeated cross-sectional intervention study at two hospital sites. | PSNet

    psnet.ahrq.gov/issue/patient-safety-culture-improves-during-situ-simulation-intervention-repeated-cross-sectional
    January 20, 2021 - during an in situ simulation intervention: a repeated cross-sectional intervention study at two hospital sites … during an in situ simulation intervention: a repeated cross-sectional intervention study at two hospital sites … during an in situ simulation intervention: a repeated cross-sectional intervention study at two hospital sites

  15. The perception of patient safety in an alternate site of care for elective surgery during the first wave of the novel coronavirus pandemic in the United Kingdom: a survey of 158 patients. | PSNet

    psnet.ahrq.gov/issue/perception-patient-safety-alternate-site-care-elective-surgery-during-first-wave-novel
    May 12, 2021 - procedures during the COVID-19 pandemic, the National Health Service utilized alternate “clean” hospital sites … patients reported high levels of confidence and satisfaction in the precautions in place at these “clean” sites

  16. A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites. | PSNet

    psnet.ahrq.gov/issue/national-survey-assessing-number-records-allowed-open-electronic-health-records-hospitals-and
    May 29, 2019 - assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites … assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites … assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites

  17. A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized clinical trial. | PSNet

    psnet.ahrq.gov/issue/virtual-breakthrough-series-collaborative-missed-test-results-stepped-wedge-cluster
    May 12, 2021 - Researchers identified improvements in follow-up rates for abnormal test results at sites with the lowest … baseline performance but did not find significant improvements across study sites overall.

  18. A mixed methods study exploring patient safety culture at 4 VHA Hospitals. | PSNet

    psnet.ahrq.gov/issue/mixed-methods-study-exploring-patient-safety-culture-4-vha-hospitals
    September 25, 2019 - This mixed methods study compared qualitative data from key informants at four VHA sites with quantitative … that qualitative data aligned with most PSC survey domains but identified significant variation across sites

  19. Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, and wrong surgical sites. | PSNet

    psnet.ahrq.gov/issue/understanding-national-coverage-policies-navigating-maze-hacs-serious-reportable-events-and
    June 28, 2017 - Navigating the maze of HACs, serious reportable events, and wrong surgical sites. … Navigating the maze of HACs, serious reportable events, and wrong surgical sites. … Navigating the maze of HACs, serious reportable events, and wrong surgical sites.

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37207/psn-pdf
    September 09, 2008 - Publicly available hospital comparison web sites: determination of useful, valid, and appropriate information … Publicly available hospital comparison web sites: determination of useful, valid, and appropriate information … https://psnet.ahrq.gov/issue/publicly-available-hospital-comparison-web-sites-determination-useful-valid … and-appropriate The growing focus on health care quality has led to the development of several Web sites … , the Joint Commission's Quality Check, the Leapfrog Group, and three commercial sites) for ease of
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