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psnet.ahrq.gov/node/39837/psn-pdf
September 15, 2010 - The efficacy of medical team training: improved team
performance and decreased operating room delays: a
detailed analysis of 4863 cases.
September 15, 2010
Wolf FA, Way LW, Stewart L. The efficacy of medical team training: improved team performance and
decreased operating room delays: a detailed analysis of 4863 c…
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psnet.ahrq.gov/node/44882/psn-pdf
July 18, 2016 - An ethical framework for allocating scarce life-saving
chemotherapy and supportive care drugs for childhood
cancer.
July 18, 2016
Unguru Y, Fernandez C, Bernhardt B, et al. An Ethical Framework for Allocating Scarce Life-Saving
Chemotherapy and Supportive Care Drugs for Childhood Cancer. J Natl Cancer Inst. 2016;1…
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psnet.ahrq.gov/node/43690/psn-pdf
March 26, 2015 - Improving healthcare systems' disclosures of large-scale
adverse events: a Department of Veterans Affairs
leadership, policymaker, research and stakeholder
partnership.
March 26, 2015
Elwy R, Bokhour BG, Maguire EM, et al. Improving healthcare systems' disclosures of large-scale adverse
events: a Department of Ve…
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psnet.ahrq.gov/node/42483/psn-pdf
January 22, 2014 - What patients think doctors know: beliefs about provider
knowledge as barriers to safe medication use.
January 22, 2014
Serper M, McCarthy D, Patzer RE, et al. What patients think doctors know: beliefs about provider
knowledge as barriers to safe medication use. Patient Educ Couns. 2013;93(2):306-11.
doi:10.1016/j…
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psnet.ahrq.gov/node/44958/psn-pdf
March 09, 2016 - The Sepsis Early Recognition and Response Initiative
(SERRI).
March 9, 2016
Jones SL, Ashton CM, Kiehne L, et al. The Sepsis Early Recognition and Response Initiative (SERRI). Jt
Comm J Qual Patient Saf. 2016;42(3):122-138.
https://psnet.ahrq.gov/issue/sepsis-early-recognition-and-response-initiative-serri
Early …
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psnet.ahrq.gov/node/42298/psn-pdf
December 31, 2014 - Using statistical text classification to identify health
information technology incidents.
December 31, 2014
Chai KEK, Anthony S, Coiera E, et al. Using statistical text classification to identify health information
technology incidents. J Am Med Inform Assoc. 2013;20(5):980-5. doi:10.1136/amiajnl-2012-001409.
htt…
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psnet.ahrq.gov/node/41557/psn-pdf
August 01, 2012 - Signal and noise: applying a laboratory trigger tool to
identify adverse drug events among primary care
patients.
August 1, 2012
Brenner S, Detz A, Lopez A, et al. Signal and noise: applying a laboratory trigger tool to identify adverse
drug events among primary care patients. BMJ Qual Saf. 2012;21(8):670-5. doi:1…
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psnet.ahrq.gov/node/43653/psn-pdf
January 01, 2015 - Evaluating inpatient mortality: a new electronic review
process that gathers information from front-line
providers.
December 19, 2014
Provenzano A, Rohan S, Trevejo E, et al. Evaluating inpatient mortality: a new electronic review process
that gathers information from front-line providers. BMJ Qual Saf. 2015;24(1)…
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psnet.ahrq.gov/node/46299/psn-pdf
September 13, 2017 - Simulation-based assessment of the management of
critical events by board-certified anesthesiologists.
September 13, 2017
Weinger MB, Banerjee A, Burden AR, et al. Simulation-based assessment of the management of critical
events by board-certified anesthesiologists. Anesthesiology. 2017;127(3):475-489.
doi:10.1097…
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psnet.ahrq.gov/node/45360/psn-pdf
July 27, 2016 - Communicating findings of delayed diagnostic evaluation
to primary care providers.
July 27, 2016
Meyer AND, Murphy DR, Singh H. Communicating Findings of Delayed Diagnostic Evaluation to Primary
Care Providers. J Am Board Fam Med. 2016;29(4):469-73. doi:10.3122/jabfm.2016.04.150363.
https://psnet.ahrq.gov/issue/co…
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psnet.ahrq.gov/node/43419/psn-pdf
October 20, 2014 - Impact of a reengineered electronic error-reporting
system on medication event reporting and care process
improvements at an urban medical center.
October 20, 2014
McKaig D, Collins C, Elsaid KA. Impact of a reengineered electronic error-reporting system on medication
event reporting and care process improvements …
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psnet.ahrq.gov/node/43279/psn-pdf
October 20, 2014 - A comprehensive obstetric patient safety program
reduces liability claims and payments.
October 20, 2014
Pettker CM, Thung SF, Lipkind HS, et al. A comprehensive obstetric patient safety program reduces liability
claims and payments. Am J Obstet Gynecol. 2014;211(4):319-25. doi:10.1016/j.ajog.2014.04.038.
https://…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - surgical sponges (gauze sponges with a
radiopaque marker) are supposed to be in each pack by
industry standards
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psnet.ahrq.gov/node/33859/psn-pdf
June 01, 2018 - In Conversation With… Richard Hoppmann, MD
June 1, 2018
In Conversation With… Richard Hoppmann, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md
Editor's note: Dr. Hoppmann is the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor
of Medicine, and Dire…
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psnet.ahrq.gov/node/846125/psn-pdf
March 15, 2023 - In this
example, to improve detection, the team decided to increase the frequency and improve standardization
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psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
August 06, 2014 - Double-Check Systems
Instituting a process for necessary lab draws, prospective pharmacist review
Standardization
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Adverse Event During Intrahospital Transport
February 1, 2019
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
The Case
A 4-year-old boy underwent surgery under general anesthesia for correction o…
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - Lost in Sign Out and Documentation
April 1, 2016
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
The Case
A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the
emergency physician, …
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psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-intervention-innovation
July 23, 2024 - System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary
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March 01, 2012 - Spotlight Case July 2008
Spotlight Case
Postdischarge Follow-Up Phone Call
*
*
Source and Credits
This presentation is based on the March 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Michelle Mourad, MD, and Stephanie Rennke, MD; Divi…