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psnet.ahrq.gov/issue/ideas-innovation-stimulating-collaborations-application-resilience-engineering-healthcare
April 24, 2013 - Audiovisual
Slideset
Published April 24, 2013
Ideas to Innovation: Stimulating Collaborations in the Application of Resilience Engineering to Healthcare.
Medstar Healthcare; University-Industry Demonstration Partnership;…
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - When stimulants wear off, users experience rebound fatigue with extreme somnolence, which has been shown … Avoid and discourage excessive use of stimulants
Clinicians should not try to overcome a sleep deficit … can induce transient hypertension and possibly tachyarrhythmias in susceptible individuals. 40,41 Stimulants
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psnet.ahrq.gov/issue/fda-public-health-notification-mri-caused-injuries-patients-implanted-neurological
August 24, 2005 - Government Resource
FDA public health notification: MRI-caused injuries in patients with implanted neurological stimulators.
Citation Text:
Schultz DG; Center for Devices and Radiological Health, Food and Drug Administration; CDRH; FDA.
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psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon
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Christian Bohringer, MBBS, and Sharon Ashley, MD
| November 30, 2023
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psnet.ahrq.gov/issue/safety-journal-lessons-learned-error-reporting-tool-stimulate-systems-thinking
June 03, 2009 - Study
The safety journal: lessons learned with an error reporting tool to stimulate systems thinking.
Citation Text:
Singh R; Naughton B; Singh A; Anderson DR; Singh G.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
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Samantha Jimenez, MD, and Stephanie Crossen, MD | March 29, 2023
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psnet.ahrq.gov/issue/informing-design-new-pragmatic-registry-stimulate-near-miss-reporting-ambulatory-care
February 05, 2014 - Review
Informing the design of a new pragmatic registry to stimulate near miss reporting in ambulatory care.
Citation Text:
Pfoh ER, Engineer L, Singh H, et al. Informing the Design of a New Pragmatic Registry to Stimulate Near Miss Reporting in Ambulatory Care. J Patient Saf. 2021;17(3)…
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psnet.ahrq.gov/issue/how-incident-reporting-systems-can-stimulate-social-and-participative-learning-mixed-methods
November 04, 2020 - Study
How incident reporting systems can stimulate social and participative learning: a mixed-methods study.
Citation Text:
de Kam D, Kok J, Grit K, Leistikow I, Vlemminx M, Bal R. How incident reporting systems can stimulate social and participative learning: A mixed-methods study. …
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psnet.ahrq.gov/issue/pharmacist-led-video-stimulated-feedback-reduce-prescribing-errors-doctors-training-mixed
August 10, 2022 - Journal Article
Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A mixed methods evaluation
Citation Text:
Parker H, Farrell O, Bethune R, et al. Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A…
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psnet.ahrq.gov/issue/pediatric-adhd-medication-exposures-reported-us-poison-control-centers
November 28, 2018 - significantly over the past two decades, accompanied by an increase in patients receiving medications (usually stimulants
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psnet.ahrq.gov/issue/surgical-crisis-management-skills-training-and-assessment-stimulation-based-approach
December 07, 2005 - Study
Surgical crisis management skills training and assessment: a stimulation-based approach to enhancing operating room performance.
Citation Text:
Moorthy K, Munz Y, Forrest D, et al. Surgical Crisis Management Skills Training and Assessment. Ann Surg. 2006;244(1). doi:10.1097/01.sl…
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psnet.ahrq.gov/web-mm/dont-bite-your-tongue
September 12, 2007 - Don’t Bite Your Tongue.
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Naileshni S. Singh, MD
| December 14, 2022
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The Case
A 63-year-old woman with a past medical history o…
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psnet.ahrq.gov/web-mm/stroke-error
December 01, 2015 - SPOTLIGHT CASE
A Stroke of Error
PPT
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Kevin M. Barrett, MD, MSc | December 1, 2014
View more articles from the same authors.
Case Objectives State the key …
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psnet.ahrq.gov/issue/kaletra-lopinavirritonavir-oral-solution
September 29, 2010 - Government Resource
Kaletra (lopinavir/ritonavir) oral solution.
Citation Text:
Food and Drug Administration; FDA.
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August 29, 2007
F…
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging
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Luciano Sanchez, PharmD, Hollie Porras, PharmD, BCPS, and Cathy Lammers, MD
| July 8, 2022
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psnet.ahrq.gov/web-mm/too-much-too-fast
January 17, 2024 - Through different mechanisms, insulin and beta-2 adrenergic stimulants increase Na-K APTase activity,
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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, …
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psnet.ahrq.gov/issue/patient-safety-here-health-texas
August 19, 2020 - Journal Article
Patient Safety: Here for the Health of Texas.
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March 6, 2005
This site provides information on health care safety with updates on cu…
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psnet.ahrq.gov/issue/patient-guide-10-ways-improve-communication-your-doctor
February 15, 2024 - Journal Article
Patient Guide: 10 Ways to Improve Communication with Your Doctor.
Citation Text:
Patient Guide: 10 Ways to Improve Communication With Your Doctor. J Patient Saf. 2008;1(4). doi:10.1097/01.jps.0000199856.82316.50.
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psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.
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Christian Bohringer, MD
| March 29, 2023
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The Cas…