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psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
July 01, 2006 - antibiotic prophylaxis, an endocrinologist if you were working on glycemic control in the intensive care unit … implemented across the entire hospital, much of the work should be done at the microsystem (ie, clinical unit
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psnet.ahrq.gov/node/865984/psn-pdf
May 29, 2024 - can then be considered for more urgent risk stratification testing in the inpatient
or observation unit
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
May 01, 2017 - Cardiothoracic surgery, cardiology, and the intensive care unit team were consulted for further management
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psnet.ahrq.gov/node/850362/psn-pdf
June 14, 2023 - Home Medications Contribute to a Unique Opportunity for
Error on Discharge from the Hospital
June 14, 2023
Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from
the Hospital. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…
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psnet.ahrq.gov/node/49471/psn-pdf
December 01, 2004 - Carpe Diem (Seize the Day)
December 1, 2004
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day
The Case
A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic
medical conditions including hypertension, h…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
April 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case April 2008
Antibiotics for URI/Sinusitis: A Simple Decision Gone Bad
Source and Credits
This presentation is based on the April 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Sumant Ranji, MD,…
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psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - Opioid Overdose as a Patient Safety Problem
May 22, 2017
Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
Perspective
Opioids serve a valuable role in the treatment of acute pain and pain associat…
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psnet.ahrq.gov/node/43571/psn-pdf
October 01, 2014 - The evolving literature on safety WalkRounds: emerging
themes and practical messages.
October 1, 2014
Singer SJ, Tucker AL. The evolving literature on safety WalkRounds: emerging themes and practical
messages: Table 1. BMJ Qual Saf. 2014;23(10). doi:10.1136/bmjqs-2014-003416.
https://psnet.ahrq.gov/issue/evolving-…
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psnet.ahrq.gov/node/41101/psn-pdf
October 16, 2012 - System-related interventions to reduce diagnostic errors:
a narrative review.
October 16, 2012
Singh H, Graber ML, Kissam SM, et al. System-related interventions to reduce diagnostic errors: a
narrative review. BMJ Qual Saf. 2012;21(2):160-170. doi:10.1136/bmjqs-2011-000150.
https://psnet.ahrq.gov/issue/system-rel…
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psnet.ahrq.gov/node/36836/psn-pdf
January 29, 2015 - Learning from Bristol: The Report of the Public Inquiry
into Children's Heart Surgery at the Bristol Royal
Infirmary 1984--1995.
January 29, 2015
Bristol Royal Infirmary Inquiry; The Stationery Office. London, England: Crown Copyright; 2002.
https://psnet.ahrq.gov/issue/learning-bristol-report-public-inquiry-child…
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psnet.ahrq.gov/node/36979/psn-pdf
February 28, 2011 - Changes in outcomes for internal medicine inpatients
after work-hour regulations.
February 28, 2011
Horwitz LI, Kosiborod M, Lin Z, et al. Changes in outcomes for internal medicine inpatients after work-hour
regulations. Ann Intern Med. 2007;147(2):97-103.
https://psnet.ahrq.gov/issue/changes-outcomes-internal-med…
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psnet.ahrq.gov/node/37961/psn-pdf
May 05, 2010 - Does the Leapfrog program help identify high-quality
hospitals?
May 5, 2010
Jha AK, Orav J, Ridgway AB, et al. Does the Leapfrog program help identify high-quality hospitals? Jt
Comm J Qual Patient Saf. 2008;34(6):318-325.
https://psnet.ahrq.gov/issue/does-leapfrog-program-help-identify-high-quality-hospitals
The…
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psnet.ahrq.gov/node/47526/psn-pdf
January 16, 2019 - US national trends in pediatric deaths from prescription
and illicit opioids, 1999–2016.
January 16, 2019
Gaither JR, Shabanova V, Leventhal JM. US National Trends in Pediatric Deaths From Prescription and
Illicit Opioids, 1999-2016. JAMA Netw Open. 2018;1(8):e186558.
doi:10.1001/jamanetworkopen.2018.6558.
https:…
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psnet.ahrq.gov/node/40473/psn-pdf
July 02, 2011 - A systematic review of failures in handoff communication
during intrahospital transfers.
July 2, 2011
Ong M-S, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers.
Jt Comm J Qual Patient Saf. 2011;37(6):274-284.
https://psnet.ahrq.gov/issue/systematic-review-failures-h…
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psnet.ahrq.gov/node/45959/psn-pdf
June 29, 2017 - Impact of the Opioid Safety Initiative on opioid-related
prescribing in veterans.
June 29, 2017
Lin LA, Bohnert ASB, Kerns RD, et al. Impact of the Opioid Safety Initiative on opioid-related prescribing in
veterans. Pain. 2017;158(5):833-839. doi:10.1097/j.pain.0000000000000837.
https://psnet.ahrq.gov/issue/impact…
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psnet.ahrq.gov/node/73707/psn-pdf
September 15, 2021 - Inpatient telemedicine and new models of care during
COVID-19: hospital design strategies to enhance patient
and staff safety.
September 15, 2021
Pilosof NP, Barrett M, Oborn E, et al. Inpatient telemedicine and new models of care during COVID-19:
hospital design strategies to enhance patient and staff safety. Int…
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psnet.ahrq.gov/node/859300/psn-pdf
January 01, 2024 - Patient safety in remote primary care encounters:
multimethod qualitative study combining Safety I and
Safety II analysis.
December 20, 2023
Payne R, Clarke A, Swann N, et al. Patient safety in remote primary care encounters: multimethod
qualitative study combining Safety I and Safety II analysis. BMJ Qual Saf. 20…
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psnet.ahrq.gov/node/45979/psn-pdf
April 05, 2017 - Healthcare system-wide implementation of opioid-safety
guideline recommendations: the case of urine drug
screening and opioid-patient suicide- and overdose-
related events in the Veterans Health Administration.
April 5, 2017
Brennan PL, Del Re AC, Henderson PT, et al. Healthcare system-wide implementation of opioi…
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psnet.ahrq.gov/node/44249/psn-pdf
February 12, 2019 - Community Pharmacy Survey on Patient Safety Culture
2015 User Comparative Database Report.
February 12, 2019
Famolaro T, Yount N, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; June
2015. AHRQ Publication No. 15-0041-EF.
https://psnet.ahrq.gov/issue/community-pharmacy-survey-patient-saf…
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psnet.ahrq.gov/node/44683/psn-pdf
June 21, 2016 - Physician spending and subsequent risk of malpractice
claims: observational study.
June 21, 2016
Jena AB, Schoemaker L, Bhattacharya J, et al. Physician spending and subsequent risk of malpractice
claims: observational study. BMJ. 2015;351:h5516. doi:10.1136/bmj.h5516.
https://psnet.ahrq.gov/issue/physician-spendi…