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psnet.ahrq.gov/issue/well-defined-pediatric-icu-active-surveillance-using-nonmedical-personnel-capture-less
July 13, 2010 - Study
The well-defined pediatric ICU: active surveillance using nonmedical personnel to capture less serious safety events.
Citation Text:
White WA, Kennedy K, Belgum HS, et al. The Well-Defined Pediatric ICU: Active Surveillance Using Nonmedical Personnel to Capture Less Serious Safety …
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psnet.ahrq.gov/issue/simulation-based-assessment-management-critical-events-board-certified-anesthesiologists
February 19, 2010 - Study
Simulation-based assessment of the management of critical events by board-certified anesthesiologists.
Citation Text:
Weinger MB, Banerjee A, Burden AR, et al. Simulation-based assessment of the management of critical events by board-certified anesthesiologists. Anesthesiology. 201…
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psnet.ahrq.gov/issue/impact-inpatient-harms-hospital-finances-and-patient-clinical-outcomes
February 28, 2018 - Study
Classic
Impact of inpatient harms on hospital finances and patient clinical outcomes.
Citation Text:
Adler L, Yi D, Li M, et al. Impact of Inpatient Harms on Hospital Finances and Patient Clinical Outcomes. J Patient Saf. 2018;14(2):67-73. doi:10.1097/PTS.…
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psnet.ahrq.gov/issue/effect-health-information-exchange-recognition-medication-discrepancies-interrupted-when-data
November 16, 2022 - Study
Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial.
Citation Text:
Boockvar K, Ho W, Pruskowski J, et al. Effect of health information exchange on recogni…
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psnet.ahrq.gov/issue/serious-misdiagnosis-related-harms-malpractice-claims-big-three-vascular-events-infections
July 28, 2023 - Study
Emerging Classic
Serious misdiagnosis-related harms in malpractice claims: the "Big Three": vascular events, infections, and cancers.
Citation Text:
Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Serious misdiagnosis-related harms in malpractice claims: T…
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psnet.ahrq.gov/innovation/assessing-impact-virtual-medication-history-technicians-medication-reconciliation
December 01, 2021 - EMERGING INNOVATIONS
Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies.
Citation Text:
Gadallah A, McGinnis B, Nguyen B, et al. Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies. Int J C…
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psnet.ahrq.gov/issue/prospective-controlled-trial-electronic-hand-hygiene-reminder-system
April 07, 2021 - Study
A prospective controlled trial of an electronic hand hygiene reminder system.
Citation Text:
Ellison RT, Barysauskas CM, Rundensteiner EA, et al. A Prospective Controlled Trial of an Electronic Hand Hygiene Reminder System. Open Forum Infect Dis. 2015;2(4):ofv121. doi:10.1093/ofid/…
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psnet.ahrq.gov/issue/health-economic-evaluation-infection-prevention-and-control-program-are-quality-and-patient
June 02, 2021 - Study
Health economic evaluation of an infection prevention and control program: are quality and patient safety programs worth the investment?
Citation Text:
Raschka S, Dempster L, Bryce E. Health economic evaluation of an infection prevention and control program: are quality and patien…
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psnet.ahrq.gov/issue/failure-utilize-functions-electronic-prescribing-system-and-subsequent-generation-technically
February 15, 2012 - Study
Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically preventable' computerized alerts.
Citation Text:
Baysari M, Reckmann MH, Li L, et al. Failure to utilize functions of an electronic prescribing system and the subsequent g…
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psnet.ahrq.gov/issue/national-cluster-randomized-trial-duty-hour-flexibility-surgical-training
September 09, 2015 - Study
Classic
National cluster-randomized trial of duty-hour flexibility in surgical training.
Citation Text:
Bilimoria KY, Chung JW, Hedges L, et al. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. New Engl J Med. 2016;374(8):71…
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psnet.ahrq.gov/issue/systematic-review-types-and-causes-prescribing-errors-generated-using-computerized-provider
July 02, 2019 - Review
A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care.
Citation Text:
Brown CL, Mulcaster HL, Triffitt KL, et al. A systematic review of the types and causes of prescribing err…
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psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - to
support clinical workflow
Development of potentially unsafe workarounds
Lack of data coding,
standardization
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psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
September 27, 2023 - Emerg Med Int . 2019;2019:3752645. [ Free full text ASGE Standards of Practice Committee; Ikenberry SO
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psnet.ahrq.gov/web-mm/carpe-diem-seize-day
September 01, 2012 - Carpe Diem (Seize the Day)
Citation Text:
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - A Seasonal Care Transition Failure
July 1, 2011
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
The Case
A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine
resident—for routine follow-up…
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages
Citation Text:
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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…
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - Staggered Sensitivity Results
Citation Text:
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/refused-medication-error
November 01, 2005 - Refused Medication Error
Citation Text:
Foley M. Refused Medication Error. 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/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
July 01, 2012 - Spotlight Case July 2008
Spotlight Case
Not-So-Therapeutic Tap
*
*
Source and Credits
This presentation is based on the July 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeffrey H. Barsuk, MD, MS; Northwestern University Feinberg Scho…
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psnet.ahrq.gov/node/33651/psn-pdf
June 01, 2007 - In Conversation with...Diane Rydrych, MA
June 1, 2007
In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
Editor's Note: Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota
Department of Health,…