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psnet.ahrq.gov/web-mm/need-eat
February 10, 2021 - The Need to Eat
Citation Text:
Widaman AM. The Need to Eat. 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/node/50755/psn-pdf
December 18, 2019 - The Need to Eat
December 18, 2019
Widaman AM. The Need to Eat. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/need-eat
The Case
A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder
caused by the lack of vitamin B1 – was admitted for possible aspiration pneum…
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/node/867651/psn-pdf
February 26, 2025 - Safety I, Safety II, and the New Views of Safety
February 26, 2025
Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
Background and Context
Safety I and Safety II (Safety I/II) are not safety method…
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psnet.ahrq.gov/issue/proportion-errors-medical-prescriptions-and-their-executions-among-hospitalized-children-and
June 15, 2012 - Study
The proportion of errors in medical prescriptions and their executions among hospitalized children before and during accreditation.
Citation Text:
Mekory TM, Bahat H, Bar-Oz B, et al. The proportion of errors in medical prescriptions and their executions among hospitalized children…
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psnet.ahrq.gov/node/73255/psn-pdf
May 12, 2021 - Implementing High-Quality Primary Care: Rebuilding the
Foundation of Health Care.
May 12, 2021
National Academies of Sciences, Engineering, and Medicine 2021. Washington, DC: The National
Academies Press.
https://psnet.ahrq.gov/issue/implementing-high-quality-primary-care-rebuilding-foundation-health-care
Primary…
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psnet.ahrq.gov/node/47819/psn-pdf
March 13, 2019 - "Does your knee make more of a click or a clack?";
teaching "Car Talk" to new docs.
March 13, 2019
Chisholm P. Health Shots. National Public Radio. February 27, 2019.
https://psnet.ahrq.gov/issue/does-your-knee-make-more-click-or-clack-teaching-car-talk-new-docs
Problem solving is a key skill for diagnosticians to…
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - Since the patient’s prior diabetic history is not described, we do not know whether he was started on
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psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - senior resident
on the neurosurgical service told the intern during the day that "heparin should be started
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psnet.ahrq.gov/node/38477/psn-pdf
October 03, 2017 - Serious Adverse Events Reports.
October 3, 2017
The Quality Improvement Committee. Wellington, New Zealand; 2006-2013.
https://psnet.ahrq.gov/issue/serious-adverse-events-reports
Considered a starting point for a national reporting initiative, this series of annual reports provides statistics
on serious and sentin…
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psnet.ahrq.gov/issue/effect-structured-medication-review-followed-face-face-feedback-prescribers-adverse-drug
January 18, 2013 - Study
The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study.
Citation Text:
Klopotowska JE, Kuks PFM, Wierenga PC, et al. The effect o…
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psnet.ahrq.gov/node/47767/psn-pdf
June 12, 2019 - Gaps in ambulatory patient safety for immunosuppressive
specialty medications.
June 12, 2019
Patterson S, Schmajuk G, Evans M, et al. Gaps in Ambulatory Patient Safety for Immunosuppressive
Specialty Medications. Jt Comm J Qual Patient Saf. 2019;45(5):348-357. doi:10.1016/j.jcjq.2018.12.003.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/837077/psn-pdf
May 11, 2022 - At US hospitals, a drug mix-up is just a few keystrokes
away.
May 11, 2022
Kelman B. Kaiser Health News. April 29, 2022.
https://psnet.ahrq.gov/issue/us-hospitals-drug-mix-just-few-keystrokes-away
Technological solutions harbor unique risks that can result in patient harm. This article shares a response
to report…
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psnet.ahrq.gov/node/33787/psn-pdf
January 01, 2018 - conversation-maureen-bisognano
http://www.ihi.org/Pages/default.aspx
http://dx.doi.org/10.1377/hlthaff.27.3.759
RW: When you started
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - Robert Wachter, Editor, AHRQ WebM&M: Reflecting back to when you started this work 15 years
ago or so
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psnet.ahrq.gov/web-mm/comanagement-whos-charge
July 01, 2011 - He was started on broad-spectrum antibiotics; however, the patient's respiratory status continued to
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psnet.ahrq.gov/node/39418/psn-pdf
March 31, 2010 - Take Charge of Your Hospital Stay to Avoid Medical
Mistakes.
March 31, 2010
Clarke S, Savard M. Good Morning America. ABC News. March 22, 2010.
https://psnet.ahrq.gov/issue/take-charge-your-hospital-stay-avoid-medical-mistakes
This television interview offers recommendations for patients to keep themselves safe wh…
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psnet.ahrq.gov/node/42534/psn-pdf
August 28, 2013 - Risk factors for hospital admissions associated with
adverse drug events.
August 28, 2013
Kongkaew C, Hann M, Mandal J, et al. Risk factors for hospital admissions associated with adverse drug
events. Pharmacotherapy. 2013;33(8):827-37. doi:10.1002/phar.1287.
https://psnet.ahrq.gov/issue/risk-factors-hospital-admi…
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psnet.ahrq.gov/node/39599/psn-pdf
December 27, 2014 - The role of housestaff in implementing medication
reconciliation on admission at an academic medical
center.
December 27, 2014
Evans AS, Lazar EJ, Tiase VL, et al. The role of housestaff in implementing medication reconciliation on
admission at an academic medical center. Am J Med Qual. 2011;26(1):39-42.
doi:10.1…
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psnet.ahrq.gov/node/40349/psn-pdf
May 11, 2011 - Use of briefings and debriefings as a tool in improving
team work, efficiency, and communication in the
operating theatre.
May 11, 2011
Bethune R, Sasirekha G, Sahu A, et al. Use of briefings and debriefings as a tool in improving team work,
efficiency, and communication in the operating theatre. Postgrad Med J. 2…