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psnet.ahrq.gov/issue/cost-effectiveness-computerized-provider-order-entry-system-improving-medication-safety
August 09, 2017 - Study
Cost-effectiveness of a computerized provider order entry system in improving medication safety ambulatory care.
Citation Text:
Forrester SH, Hepp Z, Roth JA, et al. Cost-Effectiveness of a Computerized Provider Order Entry System in Improving Medication Safety Ambulatory Care. Val…
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psnet.ahrq.gov/issue/managing-prevention-retained-surgical-instruments-what-value-counting
September 25, 2008 - Study
Classic
Managing the prevention of retained surgical instruments: what is the value of counting?
Citation Text:
Egorova NN, Moskowitz A, Gelijns A, et al. Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg. …
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psnet.ahrq.gov/issue/impact-coronavirus-disease-2019-covid-19-healthcare-associated-infections-2020-summary-data
February 07, 2022 - Study
The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network.
Citation Text:
Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. The impact of coronavirus disease 2019 (COVID-1…
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psnet.ahrq.gov/issue/cancer-diagnostic-delay-northern-and-central-italy-during-2020-lockdown-due-coronavirus
March 08, 2023 - Study
Cancer diagnostic delay in Northern and Central Italy during the 2020 lockdown due to the coronavirus disease 2019 pandemic.
Citation Text:
Ferrara G, De Vincentiis L, Ambrosini-Spaltro A, et al. Cancer diagnostic delay in Northern and Central Italy during the 2020 lockdown due to …
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psnet.ahrq.gov/issue/clinical-characteristics-and-short-term-outcomes-acute-kidney-injury-missed-diagnosis-older
April 20, 2022 - Study
Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.
Citation Text:
Li Q, Hu P, Kang H, et al. Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis…
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psnet.ahrq.gov/issue/nosocomial-transmission-and-outbreaks-coronavirus-disease-2019-need-protect-both-patients-and
February 07, 2022 - Review
Nosocomial transmission and outbreaks of coronavirus disease 2019: the need to protect both patients and healthcare workers.
Citation Text:
Abbas M, Robalo Nunes T, Martischang R, et al. Nosocomial transmission and outbreaks of coronavirus disease 2019: the need to protect both pa…
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psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
April 24, 2024 - associated with infections. 25,26 For example, in a study of 28,205 home health care patients with urinary … catheters, the lack of appropriate policies resulted in a 21% higher probability of hospital transfer … Urinary catheter policies in home healthcare agencies and hospital transfers due to urinary tract infection
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psnet.ahrq.gov/issue/creating-high-reliability-health-care-system-improving-performance-core-processes-care-johns
January 27, 2016 - Study
Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine.
Citation Text:
Pronovost P, Armstrong M, Demski R, et al. Creating a high-reliability health care system: improving performance on core processes of care at Jo…
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - Hyperkalemia needs to be treated urgently. 19 A urinary catheter should be inserted to monitor for the
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psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
May 01, 2012 - Situational Awareness and Patient Safety
Citation Text:
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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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
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Chakraborti C, Kahn MJ, Krane K. Operatio…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
January 29, 2020 - Delayed Diagnosis of Kidney Transplant Complications
Citation Text:
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
April 17, 2025 - Breadcrumb
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Created By: Maria Mirica, PRIDE Group
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psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - December 23, 2020
WebM&M Cases
Unseen Perils of Urinary … Catheters
June 1, 2015
Multi-team shared expectations tool (MT-SET): an exercise
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psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - equipment; instituting surveillance and prevention of device-associated infections (e.g., central lines, urinary … catheters, ventilators, surgical implants, hemodialysis) and surgical site infections; implementing
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psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
July 08, 2022 - Red rubber catheters were used as tourniquets during surgery, intermittent urinary catheters, and feeding
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - medications that could increase their risk of falls or bleeding, patients with indwelling central venous or urinary … catheters, or patients with similar names.
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psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-errors-operating-room
January 29, 2021 - When the nurse went to connect the irrigation solution to the patient’s urinary catheter, it was found
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psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
September 01, 2017 - August 20, 2018
WebM&M Cases
Unseen Perils of Urinary … Catheters
June 1, 2015
An objective methodology for task analysis and workload
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psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
March 01, 2014 - equipment; instituting surveillance and prevention of device-associated infections (e.g., central lines, urinary … catheters, ventilators, surgical implants, hemodialysis) and surgical site infections; implementing