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  1. Mother's Milk, but Whose Mother? | PSNet

    psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
    November 15, 2023 - Ensuring effective care transition communication: implementation of an electronic medical record-based tool

  2. Wrong Catheter in the Right Patient | PSNet

    psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
    May 16, 2022 - Verbal orders are an important tool that can help expedite care by allowing a proxy to enter orders when

  3. Delay in Initiating Antibiotics Results in Fatal Error | PSNet

    psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
    August 02, 2015 - Residents in our program have embraced this anonymous reporting tool as a way to improve the system of

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42474/psn-pdf
    September 19, 2015 - Based on analysis of four studies using the Global Trigger Tool, the study concludes that between 210,000 … Although the accuracy of the Global Trigger Tool for assessing preventability of harm has been questioned … psnet.ahrq.gov/issue/err-human-building-safer-health-system https://psnet.ahrq.gov/issue/ihi-global-trigger-tool-measuring-adverse-events

  5. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. | PSNet

    psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
    November 16, 2022 - Diagnosis March 1, 2017 View More Related Resources Handoff tool

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33583/psn-pdf
    March 01, 2023 - Simulation is a useful tool to improve patient outcomes, improve teamwork, reduce adverse events and

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61082/psn-pdf
    July 23, 2020 - training that is available online, along with a requirements compliance facility self-assessment survey tool

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39813/psn-pdf
    October 11, 2010 - This study describes a cardiopulmonary resuscitation (CPR) debriefing tool to guide postcode discussion … The authors share the practical development of the tool, its application, and lessons learned from implementation … They highlight how the tool and postcode discussions have guided identification and resolution of issues

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49429/psn-pdf
    January 01, 2004 - Ruptured Heterotopic Pregnancy January 1, 2004 Cedars MI. Ruptured Heterotopic Pregnancy. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy The Case A 43-year-old woman, gravida 3 para 2, presented at 16 weeks' gestational age with abdominal pain. Her current pregnancy was the r…

  10. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.ppt
    February 01, 2011 - Spotlight Case July 2008 Spotlight Case One Toxic Drug Is Not Like Another * * Source and Credits This presentation is based on the February 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Eric S. Holmboe, MD, American Board of Internal…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49418/psn-pdf
    October 01, 2003 - Charcoal Lavage of the Lungs October 1, 2003 Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/charcoal-lavage-lungs The Case A 47-year-old man presented to an emergency department (ED) with altered mental status, and was believed to have a probable overdose. He receiv…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49652/psn-pdf
    May 01, 2012 - Double Dose at Transfer May 1, 2012 Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/double-dose-transfer The Case A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department (ED) for left lower extremity pain, swelling, and erythe…

  13. Leadership Role in Improving Safety | PSNet

    psnet.ahrq.gov/primer/leadership-role-improving-safety
    September 15, 2024 - Leadership Role in Improving Safety Citation Text: Leadership Role in Improving Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

  14. Readmissions and Adverse Events After Discharge | PSNet

    psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
    April 27, 2022 - Readmissions and Adverse Events After Discharge Citation Text: Readmissions and Adverse Events After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  15. Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. | PSNet

    psnet.ahrq.gov/issue/tapping-front-line-knowledge-identifying-problems-they-occur-helps-enhance-patient-safety
    July 21, 2009 - July 21, 2009 A trigger tool to identify adverse events in the intensive care unit.  … Development and evaluation of the Institute for Healthcare Improvement global trigger tool … April 4, 2011 'Global Trigger Tool' shows that adverse events in hospitals may be ten … April 1, 2010 Adverse drug event trigger tool: a practical methodology for measuring

  16. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy | PSNet

    psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
    September 30, 2020 - Use of Maternal Early Warning Trigger tool reduces maternal morbidity.

  17. Cognitive Overload in the ICU | PSNet

    psnet.ahrq.gov/web-mm/cognitive-overload-icu
    June 01, 2005 - SPOTLIGHT CASE Cognitive Overload in the ICU Citation Text: Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTe…

  18. Privacy or Safety? | PSNet

    psnet.ahrq.gov/web-mm/privacy-or-safety
    December 01, 2011 - SPOTLIGHT CASE Privacy or Safety? Citation Text: Halamka JD, McGraw D. Privacy or Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

  19. Right Regimen, Wrong Cancer: Patient Catches Medical Error | PSNet

    psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
    August 01, 2006 - a synoptic chemotherapy treatment plan has been advocated by the ASCO as a structured communication tool

  20. Medication Reconciliation With a Twist (or Dare We Say, a Patch?) | PSNet

    psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
    April 03, 2024 - SPOTLIGHT CASE Medication Reconciliation With a Twist (or Dare We Say, a Patch?) Citation Text: Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…
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