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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - Infection After Carpal Tunnel Surgery
August 28, 2024
Szabo RM. Infection After Carpal Tunnel Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
The Case
A woman presented for surgery on her right wrist as a treatment for carpal tunnel syndrome. There were no
repo…
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psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
September 01, 2007 - Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix
Leo A. Gordon, MD | September 1, 2007
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Citation Text:
Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The…
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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers
Chayan Chakraborti, MD; Marc J. Kahn, MD; N. Kevin Krane, MD | August 1, 2010
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Citation Text:
Chakraborti C, Kahn MJ, Krane K. Operatio…
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only
Spotlight
Delay in Appropriate Diagnosis and
Treatment Leading to Death from
Pulmonary Embolism
Source and Credits
• This presentation is based on the February 2021 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - Infection After Carpal Tunnel Surgery
Citation Text:
Szabo RM. Infection After Carpal Tunnel Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
September 27, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up
Citation Text:
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
June 01, 2005 - available in book form [ 4 ]) presents many of the key issues facing the interpretation of different study types
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psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - available in book form [ 4 ]) presents many of the key issues facing the interpretation of different study types
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - Sarah Mossburg: What types of information are typically reported through learning systems?
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psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
November 01, 2017 - Everything we know about human–computer interaction is that different types of people need different
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - The American Board of Medical Specialties is asking
https://psnet.ahrq.gov/issue/types-and-origins-diagnostic-errors-primary-care-settings
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psnet.ahrq.gov/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
May 26, 2021 - that any downward trends in suicide rates may not continue. 2 While a large published series of all types
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psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
November 01, 2017 - Everything we know about human–computer interaction is that different types of people need different
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - and
disability than any other category.
36
Approach to Improving Safety (2)
• There are three types
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
July 30, 2020 - Detection of SARS-CoV-2 in different types of clinical specimens. JAMA . 2020;323(18):1843-1844.
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psnet.ahrq.gov/perspective/update-safety-culture
January 22, 2020 - Update on Safety Culture
Allan Frankel, MD, and Michael Leonard, MD | August 22, 2013
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Citation Text:
Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qual…
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psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - Patient Mix-Up
Citation Text:
Shojania KG. Patient Mix-Up. 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/resuscitate-or-not
November 01, 2011 - To Resuscitate or Not?
Citation Text:
Wu AW, Pronovost P. To Resuscitate or Not?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/840255/psn-pdf
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model
to Advance Patient Safety in Care Transitions
November 16, 2022
Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to
Advance Patient Safety in Care Transitions . PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspecti…
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Adverse Event During Intrahospital Transport
February 1, 2019
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
The Case
A 4-year-old boy underwent surgery under general anesthesia for correction o…