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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.95_slideshow.ppt
May 01, 2005 - presentations
Failure to consider the consequences of competing diagnoses
Case: “Doctor Don’t Treat
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psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation?
Ashish K. Jha, MD, MPH | September 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Jha AK. What Can the Rest of the Heal…
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psnet.ahrq.gov/node/38277/psn-pdf
December 10, 2008 - Time for a change in injury and trauma care delivery: a
trauma death review analysis.
December 10, 2008
Sugrue M, Caldwell E, D'Amours S, et al. Time for a change in injury and trauma care delivery: a trauma
death review analysis. ANZ J Surg. 2008;78(11):949-954. doi:10.1111/j.1445-2197.2008.04711.x.
https://psnet…
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psnet.ahrq.gov/node/47658/psn-pdf
December 12, 2018 - Heartbroken.
December 12, 2018
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
https://psnet.ahrq.gov/issue/heartbroken
Pediatric cardiac surgery is a high-risk practice. This news investigation reports on a series of serious
patient safety incidents at a health care institute dedicated to treating heart pr…
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psnet.ahrq.gov/node/39488/psn-pdf
September 29, 2017 - CMS changes in reimbursement for HAIs: setting a
research agenda.
September 29, 2017
Stone PW, Glied SA, McNair PD, et al. CMS changes in reimbursement for HAIs: setting a research
agenda. Med Care. 2010;48(5):433-9. doi:10.1097/MLR.0b013e3181d5fb3f.
https://psnet.ahrq.gov/issue/cms-changes-reimbursement-hais-sett…
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psnet.ahrq.gov/web-mm/lp-or-not-lp
February 01, 2018 - To LP or Not LP
Citation Text:
Landrigan CP. To LP or Not LP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - SPOTLIGHT CASE
Double Trouble
Citation Text:
Gurwitz JH. Double Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/45307/psn-pdf
September 07, 2016 - End Sepsis.
September 7, 2016
1212 Avenue of the Americas, 5th Floor, New York, NY 10036. 212-244-
6294 contact@endsepsis.org
https://psnet.ahrq.gov/issue/rory-staunton-foundation-sepsis-prevention
Sepsis is a serious condition that can be rapidly fatal if it is not promptly diagnosed and treated. T…
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psnet.ahrq.gov/node/37774/psn-pdf
June 11, 2008 - Frequency of medication errors with intravenous
acetylcysteine for acetaminophen overdose.
June 11, 2008
Hayes BD, Klein-Schwartz W, Doyon S. Frequency of medication errors with intravenous acetylcysteine for
acetaminophen overdose. Ann Pharmacother. 2008;42(6):766-70. doi:10.1345/aph.1K685.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - associated with rtPA use, the majority of medicolegal outcomes
related to rtPA are for failure to treat
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psnet.ahrq.gov/node/45938/psn-pdf
September 29, 2017 - Is excessive resource utilization an adverse event?
September 29, 2017
Zapata JA, Lai AR, Moriates C. Is Excessive Resource Utilization an Adverse Event? JAMA.
2017;317(8):849-850. doi:10.1001/jama.2017.0698.
https://psnet.ahrq.gov/issue/excessive-resource-utilization-adverse-event
Overuse of therapies, medication…
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psnet.ahrq.gov/node/43700/psn-pdf
November 19, 2014 - Appropriate use of medical interpreters.
November 19, 2014
Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician. 2014;90(7):476-80.
https://psnet.ahrq.gov/issue/appropriate-use-medical-interpreters
Language barriers between patients and providers can contribute to misunderstandings and lead…
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psnet.ahrq.gov/node/41953/psn-pdf
June 19, 2013 - Potentially inappropriate medications in a large cohort of
patients in geriatric units: association with clinical and
functional characteristics.
June 19, 2013
Fromm MF, Maas R, Tümena T, et al. Potentially inappropriate medications in a large cohort of patients in
geriatric units: association with clinical and fu…
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psnet.ahrq.gov/node/38559/psn-pdf
June 16, 2009 - Regional surveillance of emergency-department visits for
outpatient adverse drug events.
June 16, 2009
Capuano A, Irpino A, Gallo M, et al. Regional surveillance of emergency-department visits for outpatient
adverse drug events. Eur J Clin Pharmacol. 2009;65(7):721-8. doi:10.1007/s00228-009-0641-8.
https://psnet.a…
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psnet.ahrq.gov/node/34915/psn-pdf
February 27, 2009 - Emergency department visits for outpatient adverse drug
events: demonstration for a national surveillance system.
February 27, 2009
Budnitz DS, Pollock DA, Mendelsohn AB, et al. Emergency department visits for outpatient adverse drug
events: demonstration for a national surveillance system. Ann Emerg Med. 2005;45(2…
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psnet.ahrq.gov/node/37347/psn-pdf
March 28, 2012 - Recognition and management of potential drug-drug
interactions in patients on internal medicine wards.
March 28, 2012
Vonbach P, Dubied A, Beer JH, et al. Recognition and management of potential drug-drug interactions in
patients on internal medicine wards. Eur J Clin Pharmacol. 2007;63(11):1075-83.
https://psnet.…
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psnet.ahrq.gov/node/44913/psn-pdf
September 27, 2017 - Nursing staff's perceptions of patient safety in psychiatric
inpatient care.
September 27, 2017
Kanerva A, Lammintakanen J, Kivinen T. Nursing Staff's Perceptions of Patient Safety in Psychiatric
Inpatient Care. Perspect Psych Care. 2016;52(1):25-31. doi:10.1111/ppc.12098.
https://psnet.ahrq.gov/issue/nursing-staf…
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psnet.ahrq.gov/node/36335/psn-pdf
February 01, 2011 - Rapid response teams—walk, don't run.
February 1, 2011
Winters BD, Pham JC, Pronovost PJ. Rapid Response Teams—Walk, Don't Run. JAMA. 2006;296(13).
doi:10.1001/jama.296.13.1645.
https://psnet.ahrq.gov/issue/rapid-response-teams-walk-dont-run
Rapid response teams (RRTs) have been widely advocated as a means of aver…
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psnet.ahrq.gov/node/34935/psn-pdf
June 23, 2009 - Improving patient care. The cognitive psychology of
missed diagnoses.
June 23, 2009
Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med.
2005;142(2):115-120.
https://psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
This case study de…
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psnet.ahrq.gov/web-mm/nonsustained-ventricular-tachycardia-after-acute-coronary-syndromes-recognizing-high-risk
September 20, 2011 - March 1, 2005
WebM&M Cases
Doctor, Don't Treat