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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
May 01, 2012 - Spotlight Case July 2008
Spotlight Case
The Perils of Cross Coverage
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Source and Credits
This presentation is based on the May 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …
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psnet.ahrq.gov/web-mm/perils-contrast-media
March 01, 2007 - SPOTLIGHT CASE
The Perils of Contrast Media
Citation Text:
Sadat U, Solomon R. The Perils of Contrast Media. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33729/psn-pdf
May 01, 2012 - The Emergence of the Trigger Tool as the Premier
Measurement Strategy for Patient Safety
May 1, 2012
Sharek PJ. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety.
PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-pa…
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Failure to Rescue the Mother
Citation Text:
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
November 15, 2023 - Complications of Vascular Access Procedures in Patients with Kidney Disease
Citation Text:
Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - SPOTLIGHT CASE
Watch the Warfarin!
Citation Text:
Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.
Citation Text:
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
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psnet.ahrq.gov/node/851568/psn-pdf
July 31, 2023 - j.ijnurstu.2015.08.012
https://doi.org/10.1002/14651858.cd009985.pub2
https://www.jointcommission.org/standards
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psnet.ahrq.gov/node/45880/psn-pdf
June 29, 2017 - Diagnostic accuracy of GPs when using an early-
intervention decision support system: a high-fidelity
simulation.
June 29, 2017
Kostopoulou O, Porat T, Corrigan D, et al. Diagnostic accuracy of GPs when using an early-intervention
decision support system: a high-fidelity simulation. Br J Gen Pract. 2017;679(656):e…
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psnet.ahrq.gov/node/41519/psn-pdf
September 01, 2016 - Failure to utilize functions of an electronic prescribing
system and the subsequent generation of 'technically
preventable' computerized alerts.
September 1, 2016
Baysari M, Reckmann MH, Li L, et al. Failure to utilize functions of an electronic prescribing system and the
subsequent generation of 'technically prev…
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psnet.ahrq.gov/node/41789/psn-pdf
September 01, 2016 - Drug–drug interactions that should be non-interruptive in
order to reduce alert fatigue in electronic health records.
September 1, 2016
Phansalkar S, van der Sijs H, Tucker AD, et al. Drug-drug interactions that should be non-interruptive in
order to reduce alert fatigue in electronic health records. J Am Med Infor…
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psnet.ahrq.gov/node/39365/psn-pdf
May 25, 2010 - Electronic prescribing improves medication safety in
community-based office practices.
May 25, 2010
Kaushal R, Kern LM, Barrón Y, et al. Electronic Prescribing Improves Medication Safety in Community-
Based Office Practices. J Gen Intern Med. 2010;25(6). doi:10.1007/s11606-009-1238-8.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/46851/psn-pdf
January 23, 2019 - To care is human—collectively confronting the clinician-
burnout crisis.
January 23, 2019
Dzau VJ, Kirch DG, Nasca TJ. To Care Is Human — Collectively Confronting the Clinician-Burnout Crisis.
New Engl J Med. 2018;378(4):312-314. doi:10.1056/nejmp1715127.
https://psnet.ahrq.gov/issue/care-human-collectively-confro…
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psnet.ahrq.gov/node/836842/psn-pdf
April 07, 2022 - Assessing the impact of virtual medication history
technicians on medication reconciliation discrepancies.
April 7, 2022
Gadallah A, McGinnis B, Nguyen B, et al. Assessing the impact of virtual medication history technicians on
medication reconciliation discrepancies. Int J Clin Pharm. 2021;43(5):1404-1411. doi:10.…
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psnet.ahrq.gov/node/37756/psn-pdf
December 15, 2008 - Do the AHRQ Patient Safety Indicators flag conditions
that are present at the time of hospital admission?
December 15, 2008
Bahl V, Thompson MA, Kau T-Y, et al. Do the AHRQ patient safety indicators flag conditions that are
present at the time of hospital admission? Med Care. 2008;46(5):516-22.
doi:10.1097/MLR.0b0…
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psnet.ahrq.gov/node/39551/psn-pdf
May 26, 2010 - Simulation-based training improves physicians'
performance in patient care in high-stakes clinical setting
of cardiac surgery.
May 26, 2010
Bruppacher HR, Alam SK, LeBlanc VR, et al. Simulation-based training improves physicians' performance
in patient care in high-stakes clinical setting of cardiac surgery. Anest…
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psnet.ahrq.gov/node/45976/psn-pdf
December 21, 2017 - Incidence of clinically relevant medication errors in the
era of electronically prepopulated medication
reconciliation forms: a retrospective chart review.
December 21, 2017
Stockton KR, Wickham ME, Lai S, et al. Incidence of clinically relevant medication errors in the era of
electronically prepopulated medicatio…
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psnet.ahrq.gov/node/42748/psn-pdf
November 20, 2013 - Effectiveness of written hospitalist sign-outs in answering
overnight inquiries.
November 20, 2013
Fogerty RL, Schoenfeld A, Al-Damluji MS, et al. Effectiveness of written hospitalist sign-outs in answering
overnight inquiries. J Hosp Med. 2013;8(11):609-14. doi:10.1002/jhm.2090.
https://psnet.ahrq.gov/issue/effec…
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psnet.ahrq.gov/node/40619/psn-pdf
October 06, 2016 - Sustaining and spreading the reduction of adverse drug
events in a multicenter collaborative.
October 6, 2016
Tham E, Calmes HM, Poppy A, et al. Sustaining and spreading the reduction of adverse drug events in a
multicenter collaborative. Pediatrics. 2011;128(2):e438-45. doi:10.1542/peds.2010-3772.
https://psnet.a…
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psnet.ahrq.gov/node/44266/psn-pdf
May 19, 2019 - Exploring health care professionals' perceptions of
incidents and incident reporting in rehabilitation settings.
May 19, 2019
Espin S, Carter C, Janes N, et al. Exploring Health Care Professionals' Perceptions of Incidents and
Incident Reporting in Rehabilitation Settings. J Patient Saf. 2019;15(2):154-160.
doi:10…