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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - Pacing threshold testing induced ventricular fibrillation following acute rate control of atrial fibrillation
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psnet.ahrq.gov/node/33708/psn-pdf
March 01, 2011 - College of Wisconsin that showed
that there is not enough literature in real-life residency settings testing
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psnet.ahrq.gov/node/836840/psn-pdf
April 22, 2021 - Testing a program that alerts hospital staff and a health educator when a patient misses a dose of
VTE
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psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - Pacing threshold testing induced ventricular fibrillation
following acute rate control of atrial fibrillation
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psnet.ahrq.gov/node/853902/psn-pdf
September 27, 2023 - Gathering and processing information, such as findings on the clinical examination and laboratory
testing
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psnet.ahrq.gov/node/74830/psn-pdf
June 01, 2022 - Making it stick: developing and testing the difficult intravenous access
(DIVA) tool.
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psnet.ahrq.gov/node/73553/psn-pdf
July 28, 2021 - College of Emergency Physicians, and I have served in various roles
with ASTM [American Society for Testing
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psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - The value of diagnostic testing in carpal tunnel syndrome .
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - Testing the association between the enabling and enacting factors of patient safety culture and patient
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
April 01, 2006 - However, we do some product testing.
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - have prompted consideration of the possibility of underlying systemic disease, even if no additional testing
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - At the hospital, testing for SARS-CoV-2, influenza, and respiratory syncytial virus (RSV) was negative
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psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - Testing a program that alerts hospital staff and a health educator when a patient misses a dose of VTE
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - problem Gathering and processing information, such as findings on the clinical examination and laboratory testing
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psnet.ahrq.gov/node/33735/psn-pdf
August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and
How to Fix It
August 1, 2012
Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
Perspective
At any point in time, …
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psnet.ahrq.gov/node/49868/psn-pdf
July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With
Dementia
July 2, 2019
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
The Case
An 86-year-old man with neurode…
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psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - Double Dosing, by the Rules
March 21, 2009
Cohen H. Double Dosing, by the Rules. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/double-dosing-rules
The Case
A 65-year-old woman with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) was
admitted to a medical unit during the night with wo…
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psnet.ahrq.gov/node/866621/psn-pdf
August 28, 2024 - Application of Safety-II Principles
August 28, 2024
Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/application-safety-ii-principles
Traditional approaches to patient safety have often been reactive rather than proactive, seeki…
-
psnet.ahrq.gov/node/33778/psn-pdf
March 01, 2015 - Diagnostic Errors
January 1, 2014
Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/diagnostic-errors
Annual Perspective 2014
Until very recently, diagnostic errors received relatively little attention in the field of patient safety,
particularly when compared wi…
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psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx
Spotlight
When the Lytes Go Out: A Case
of Inpatient Cardiac Arrest
Source and Credits
• This presentation is based on the September 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psne…