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psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
January 07, 2015 - Haste Makes Care Unsafe
Citation Text:
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - WebM&M: Case Studies
WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-slides.html
October 01, 2020 - Essential imaging available
Risk of hypothermia - operation >1 hour
Warmer in place
Risk of venous … thromboembolism
Boots and/or anticoagulants in place
Anesthesia safety check is completed
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www.ahrq.gov/ncepcr/reports/2025-annual-report/overview.html
August 01, 2025 - tract infections (UTIs), renal injury from febrile urinary tract infection, vascular anomalies, and venous … thromboembolism.
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psnet.ahrq.gov/node/33793/psn-pdf
November 01, 2015 - research-oriented snails, some
research on clinical interventions to prevent hospital–acquired adverse events, VTE … If I want to know if something new has come out on venous thromboembolism, I can easily
create an automatic
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psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
February 26, 2025 - research-oriented snails, some research on clinical interventions to prevent hospital–acquired adverse events, VTE … If I want to know if something new has come out on venous thromboembolism, I can easily create an automatic
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psnet.ahrq.gov/node/49786/psn-pdf
March 01, 2017 - illness scripts is a type of heuristic—for example, remembering the association between long
flights and venous … thromboembolism or that Lyme disease is associated with tick bites in New England.
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www.ahrq.gov/hai/tools/mvp/modules/vae/overview-off-ventilator-fac-guide.html
February 01, 2017 - It could be a patient fall, a venous thromboembolism, a medication error, ventilator associated pneumonia
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
January 01, 2014 - Over time, they will add the device/
health information technology, perinatal, and venous
thromboembolism
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psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
March 31, 2021 - How valid is the ICD-9-CM based AHRQ Patient Safety Indicator for postoperative venous … thromboembolism?
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psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - For example, an initiative designed to increase the use of
venous thromboembolism prophylaxis that did
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
April 01, 2025 - He assessed the patient for her venous thromboembolism (VTE) risk and followed the VTE risk protocol, … this scenario: at an All-Staff meeting, a senior executive tells staff to review a checklist about VTE
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www.ahrq.gov/ncepcr/tools/confid-report/system-design.html
February 01, 2016 - Computerized physician order entry with medication error detection
Example: Use of prophylaxis for venous … thromboembolism in appropriate patients
Example: Postoperative deep vein thrombosis or pulmonary embolism
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/overview-ptsoffventilator-facguide.docx
January 01, 2017 - It could be a patient fall, a venous thromboembolism, a medication error, ventilator associated pneumonia
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effectivehealthcare.ahrq.gov/sites/default/files/ch_11-user-guide-to-ocer_130129.pdf
January 03, 2012 - For
example, the risk of venous thromboembolism
rises with duration of use for oral contraceptives; … First-time use
of newer oral contraceptives and the risk of venous
thromboembolism.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-core-measures-quality.pdf
January 01, 2019 - adverse events in adults receiving knee
replacement (MPSMS)
2.6% in 2014 2.5% in 2017 0.1 0.996
Venous … Thromboembolism
Adult surgery patients with postoperative venous
thromboembolic events (MPSMS)
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - The Inside of a Time Out
Citation Text:
Feldman DL. The Inside of a Time Out. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-medications-for-risk-reduction
September 03, 2019 - ) events, or stroke. 3
When compared with placebo, raloxifene was associated with 7 more cases of VTE … on the STAR trial, more harms were reported with tamoxifen compared with raloxifene: 4 more cases of VTE
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening-june-2018
June 26, 2018 - Health Initiative trial, the previous review found an increased rate of gallbladder events, stroke, and venous … thromboembolism with estrogen therapy, and an increased risk of urinary incontinence during 1 year of … invasive breast cancer, coronary heart disease, probable dementia, gallbladder events, stroke, and venous … thromboembolism compared with women taking placebo, and an increased risk of urinary incontinence during