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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Implementation of Patient Safety Projects
Curated Library
Foundations
Leading change: why transformation efforts fail.
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
Kotter, a professor at Harvard Business School, outlines the eight stages …
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
January 01, 2022 - Spotlight
Spotlight
Perioperative Anaphylaxis After Insertion of
a Latex Drain in a Patient with Known Latex
Allergy
Source and Credits
• This presentation is based on the August 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by K…
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psnet.ahrq.gov/node/33791/psn-pdf
September 01, 2015 - In Conversation With… Vineet Arora, MD, MAPP
September 1, 2015
In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
Editor's note: Vineet Arora, MD, MAPP, is Director of GME Clinical Learning Environment Innovation,
Associate Pr…
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - divided into
specialized ECMO support (e.g., an ECMO physician, perfusionist or ECMO specialist nurse, surgeon
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psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19
August 31, 2020 - Neri Cohen, a Cardiovascular and Thoracic Surgeon and informaticist. In this role, Dr. … An orthopedic surgeon has to be able to examine your knee to figure out your restriction to motion and … A general surgeon has to be able to examine you to get a literal feel for your hernia.
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psnet.ahrq.gov/web-mm/too-hot-comfort
May 19, 2015 - However, every burn surgeon has seen iatrogenic burn injury as the result of “therapeutic” application
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psnet.ahrq.gov/node/49837/psn-pdf
August 01, 2018 - Guidelines from the Society for Vascular Surgery suggest referral to a
vascular surgeon at the time
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psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - Promising Areas for Patient Safety Research
December 1, 2003
Critical role of the surgeon–anesthesiologist
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Approach to Improving Safety (3)
• Procedure itself was complicated - an experienced orthopedic
surgeon
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psnet.ahrq.gov/issue/impact-educational-initiative-targeting-non-radiologist-staff-overall-notification-times
March 09, 2022 - Study
Impact of an educational initiative targeting non-radiologist staff on overall notification times of critical findings in radiology
Citation Text:
Zapata JFO. Impact of an educational initiative targeting non-radiologist staff on overall notification times of critical findings in r…
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psnet.ahrq.gov/node/33761/psn-pdf
February 01, 2014 - Interruptions and Distractions in Health Care: Improved
Safety With Mindfulness
February 1, 2014
Beyea SC. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness. PSNet
[internet]. 2014.
https://psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulne…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
December 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case December 2007
Elopement
Source and Credits
This presentation is based on the December 2007 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Debra Gerardi, RN, MPH, JD
Creighton University School of Law
Ed…
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psnet.ahrq.gov/node/33749/psn-pdf
April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety?
April 1, 2013
Fletcher KE, Reed DA. Are Residency Duty Hour Rules Improving Patient Safety? PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
Perspective
Introduction
The Accreditation Council f…
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psnet.ahrq.gov/node/50393/psn-pdf
September 01, 2019 - Patient Safety and the Evolution of WebM&M and PSNet
September 1, 2019
Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
Perspective
Progress in any field requires scholarship and dissem…
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psnet.ahrq.gov/issue/reflecting-change
December 02, 2009 - November 29, 2006
The good, the bad, and the ugly: operative staff perspectives of surgeon
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psnet.ahrq.gov/issue/managing-risk-systems-approach-versus-personal-responsibility-hospital-incidents
November 25, 2015 - October 13, 2021
Dual surgeon operating to improve patient safety.
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psnet.ahrq.gov/periodic-issue/periodic-issue-449
July 10, 2024 - Each time, the surgeon ordered hetastarch for volume expansion.
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psnet.ahrq.gov/web-mm/raise-bar
May 29, 2024 - The patient was then taken to the operating room, where he awaited the arrival of the surgeon.
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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - When should a surgical resident call an attending surgeon? J Surg Educ. 2008;65:206-212.
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psnet.ahrq.gov/node/49433/psn-pdf
June 23, 2021 - One cardiac surgeon and his team were identified as having higher infection rates than others,
even