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psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
June 01, 2014 - if you do these subconscious activities and the circumstances are the same, these habits become more accurate
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - physicians comfort that further actions (such as surgery) will be based on the most up-to-date and accurate
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psnet.ahrq.gov/node/49675/psn-pdf
February 01, 2013 - The Commentary
The process of arriving at an accurate diagnosis often involves many steps in a complex
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psnet.ahrq.gov/node/49825/psn-pdf
April 01, 2018 - intended message.(28) However, there remains a need for
technological advances to deliver reliably accurate
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - fatigue, or desensitization from overexposure to alarms that are false
(inaccurate) and nonactionable (accurate
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - patient misidentification, additional results, considerations for sustaining the innovation, and ensuring accurate
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psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
February 26, 2025 - There are proponents of "never events" as a title, and other people that think either it's not quite accurate
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psnet.ahrq.gov/node/49615/psn-pdf
December 01, 2010 - heel ulcer).(10) Skin changes identified on or after admission may mimic other conditions,
making accurate
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - patient care needs in the specialty, or the system may fail to design call or duty schedules that ensure accurate
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - Various approaches are used to obtain the most accurate information, including use of at least two sources
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psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
July 10, 2024 - This stream of data has become more comprehensive and more accurate over the years.
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - Related Resources
WebM&M Cases
Don’t Wait to Collect an Accurate
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psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - SPOTLIGHT CASE
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
Citation Text:
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - The COVID-19 pandemic reinforces the importance of accurate and timely communication of test results
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - The performance of the 911 center and its ability to triage calls to get accurate information when it
-
psnet.ahrq.gov/node/33717/psn-pdf
September 01, 2011 - Incident Reporting: More Attention to the Safety Action
Feedback Loop, Please
September 1, 2011
Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet
[internet]. 2011.
https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
…
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psnet.ahrq.gov/node/73650/psn-pdf
August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with
Recurrent Pneumothorax
August 25, 2021
Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent
Pneumothorax. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding
September 1, 2017
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
Case Objectives
Describe risk factors for poor outcome in patients w…
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - The Result Stopped Here
June 1, 2004
Astion ML. The Result Stopped Here. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/result-stopped-here
The Case
A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital
for continued wound care and intravenous (IV) antib…
-
psnet.ahrq.gov/node/49783/psn-pdf
February 01, 2017 - The Hazards of Distraction: Ticking All the EHR Boxes
February 1, 2017
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
Case Objectives
List the goals of having order sets in the electronic health record…