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  1. psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - SPOTLIGHT CASE CE/MOC New Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery PPT Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Christian Bohring…
  2. psnet.ahrq.gov/issue/gift-failure-new-approaches-analyzing-and-learning-events-and-near-misses
    March 06, 2005 - Special or Theme Issue The Gift of Failure: New Approaches to Analyzing and Learning from Events and Near-Misses. Citation Text: Fahlbruch B, Carroll JS, eds. Safety Sci. 2011;49(1):1-106   Copy Citation Save Save to your library Print Share …
  3. psnet.ahrq.gov/issue/using-external-errors-signal-clear-and-present-danger
    August 06, 2008 - Newspaper/Magazine Article Using external errors to signal a clear and present danger. Citation Text: ISMP Medication Safety Alert! Acute Care Edition. November 6, 2008;13:1-2. Copy Citation Save Save to your library Print Share Facebook Twit…
  4. psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
    March 29, 2023 - Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Christian Bohringer, MD | March 15, 2023 View more articl…
  5. psnet.ahrq.gov/issue/action-research-simulation-team-communication-and-bringing-tacit-voice-society-simulation
    October 03, 2018 - Study Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare. Citation Text: Forsythe L. Action research, simulation, team communication, and bringing the tacit into voice society for simulation in healthcare. Simul Heal…
  6. psnet.ahrq.gov/issue/can-we-use-incident-reports-detect-hospital-adverse-events
    March 06, 2005 - Study Can we use incident reports to detect hospital adverse events? Citation Text: Blais R; Bruno D; Bartlett G; Tamblyn R. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL …
  7. psnet.ahrq.gov/issue/reporting-and-using-near-miss-events-improve-patient-safety-diverse-primary-care-practices
    June 22, 2011 - Study Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes. Citation Text: Crane S, Sloane PD, Elder NC, et al. Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Pr…
  8. psnet.ahrq.gov/issue/close-calls-patient-safety-should-we-be-paying-closer-attention
    February 12, 2014 - Commentary Close calls in patient safety: should we be paying closer attention? Citation Text: Wu AW, Marks CM. Close calls in patient safety: should we be paying closer attention? CMAJ. 2013;185(13):1119-20. doi:10.1503/cmaj.130014. Copy Citation Format: DOI Google Schol…
  9. psnet.ahrq.gov/issue/patient-safety-objective-structured-clinical-examination
    September 12, 2007 - Study A patient safety objective structured clinical examination. Citation Text: Singh R, Singh A, Fish R, et al. A patient safety objective structured clinical examination. J Patient Saf. 2009;5(2):55-60. doi:10.1097/PTS.0b013e31819d65c2. Copy Citation Format: DOI Google…
  10. psnet.ahrq.gov/issue/prevention-potential-errors-resuscitation-medications-orders-means-computerised-physician
    January 25, 2006 - Study Prevention of potential errors in resuscitation medications orders by means of a computerised physician order entry in paediatric critical care. Citation Text: Vardi A; Efrati O; Levin I; Matok I; Rubinstein M; Paret G; Barzilay Z. Copy Citation Save Save …
  11. psnet.ahrq.gov/issue/crowdsourcing-diagnosis-patients-undiagnosed-illnesses-evaluation-crowdmed
    March 06, 2013 - Study Crowdsourcing diagnosis for patients with undiagnosed illnesses: an evaluation of CrowdMed. Citation Text: Meyer AND, Longhurst CA, Singh H. Crowdsourcing Diagnosis for Patients With Undiagnosed Illnesses: An Evaluation of CrowdMed. J Med Internet Res. 2016;18(1):e12. doi:10.2196/j…
  12. psnet.ahrq.gov/issue/preventing-overdiagnosis-how-stop-harming-healthy
    May 18, 2016 - Commentary Preventing overdiagnosis: how to stop harming the healthy. Citation Text: Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ. 2012;344:e3502. Published 2012 May 28. doi:10.1136/bmj.e3502 Copy Citation Format: DOI G…
  13. psnet.ahrq.gov/issue/avoidability-hospital-deaths-and-association-hospital-wide-mortality-ratios-retrospective
    November 12, 2014 - Study Classic Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis. Citation Text: Hogan H, Zipfel R, Neuburger J, et al. Avoidability of hospital deaths and association wit…
  14. psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
    September 26, 2023 - In Conversation With… Thomas J. Nasca, MD, MACP April 1, 2016  Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Editor's note: Dr. Nasca is Chief Executive Officer of the Accredita…
  15. psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
    December 23, 2020 - SPOTLIGHT CASE Recurrent Hypoglycemia: A Care Transition Failure? PPT Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Ted Eytan, MD, MS, MPH | October 1, 2008 View more articles from the same authors. Case …
  16. psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
    January 01, 2016 - Annual Perspective Computerized Provider Order Entry and Patient Safety Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015  View more articles from the same authors. Save Save to your library Print Share Facebook Twitt…
  17. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
    October 01, 2008 - Spotlight Case July 2008 Spotlight Case Recurrent Hypoglycemia: A Care Transition Failure? * * Source and Credits This presentation is based on the October 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Ted Eytan, MD, MS, MPH Editor, …
  18. psnet.ahrq.gov/issue/patients-willingness-and-ability-participate-actively-reduction-clinical-errors-systematic
    February 24, 2021 - Review Patients' willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review. Citation Text: DOHERTY CAROLE, STAVROPOULOU CHARITINI. Patients' willingness and ability to participate actively in the reduction of clinical errors: a …
  19. psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
    March 29, 2023 - An Incomplete Anesthesia History Leads to Adverse Outcomes Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Christian Bohringer, MD | July 8, 2022 View more articles from the same authors. The Cases Case 1: A 64-yea…
  20. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
    May 01, 2009 - Spotlight Case July 2008 Spotlight Case Delirium or Dementia? Source and Credits This presentation is based on the May 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: James L. Rudolph, MD, SM Editor, AHRQ WebM&M: Robert Wachter, MD Sp…

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