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2201. Spotlight: Mistaken Attribution, Diagnostic Misstep | PSNet
      psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
      July 01, 2011 - Inpatient diagnostic assessments: 1. accuracy of structured vs. unstructured interviews.

2202. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? | PSNet
      psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
      March 01, 2015 - hospitals, lower morale and public confidence, and encourage "gaming"—for example by upgrading risk assessments—or

2203. A Loss of Trust and a Missed Diagnosis | PSNet
      psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
      October 31, 2023 - weakness, muscle spasm, or sensory abnormalities; and Appointments moved to virtual visits, which made assessments

2204. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case | PSNet
      psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
      October 02, 2013 - correct diagnostic process (compared with violations of therapeutic guidelines) all make retrospective assessments

2205. In Conversation With… Brian Jarman, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
      March 01, 2015 - hospitals, lower morale and public confidence, and encourage "gaming"—for example by upgrading risk assessments—or

2206. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50755/psn-pdf
      December 18, 2019 - The Need to Eat December 18, 2019 Widaman AM. The Need to Eat. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/need-eat The Case A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder caused by the lack of vitamin B1 – was admitted for possible aspiration pneum…

2207. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49834/psn-pdf
      July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety July 1, 2018 Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety Case Objectives Unders…

2208. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia | PSNet
      psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
      January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia Citation Text: Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…

2209. In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles | PSNet
      psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
      August 28, 2024 - adverse events by using tools such as root cause analysis to evaluate contributing factors and risk assessments

2210. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49806/psn-pdf
      September 01, 2017 - Failed Interpretation of Screening Tool: Delayed Treatment September 1, 2017 Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment The Case An 88-year-old man present…

2211. Discharge Against Medical Advice | PSNet
      psnet.ahrq.gov/web-mm/discharge-against-medical-advice
      July 01, 2017 - Discharge Against Medical Advice Citation Text: Hwang SW. Discharge Against Medical Advice. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…

2212. Patient Safety Indicators | PSNet
      psnet.ahrq.gov/primer/patient-safety-indicators
      June 15, 2024 - Patient Safety Indicators Citation Text: Tokareva I, Romano P. Patient Safety Indicators.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…

2213. Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
      January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx Spotlight When the Indications for Drug Administration Blur Source and Credits • This presentation is based on the June 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Julia Munsch,…

2214. Detection of Safety Hazards | PSNet
      psnet.ahrq.gov/primer/detection-safety-hazards
      March 30, 2022 - Detection of Safety Hazards Citation Text: Detection of Safety Hazards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…

2215. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33582/psn-pdf
      September 15, 2024 - Detection of Safety Hazards September 15, 2024 Detection of Safety Hazards. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/detection-safety-hazards PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient s…

2216. Cognitive bias in clinical practice—nurturing healthy skepticism among medical students. | PSNet
      psnet.ahrq.gov/issue/cognitive-bias-clinical-practice-nurturing-healthy-skepticism-among-medical-students
      August 07, 2024 - Commentary Cognitive bias in clinical practice—nurturing healthy skepticism among medical students. Citation Text: Bhatti A. Cognitive bias in clinical practice - nurturing healthy skepticism among medical students. Adv Med Educ Pract. 2018;9:235-237. doi:10.2147/AMEP.S149558. Copy Cit…

2217. eHealth for Safety: Impact of ICT on Patient Safety and Risk Management. | PSNet
      psnet.ahrq.gov/issue/ehealth-safety-impact-ict-patient-safety-and-risk-management
      June 18, 2013 - Book/Report eHealth for Safety: Impact of ICT on Patient Safety and Risk Management. Citation Text: eHealth for Safety: Impact of ICT on Patient Safety and Risk Management. European Commission Information Society and Media. October 2007 Copy Citation Save Save…

2218. Correlates of Medication Error in Hospitals. | PSNet
      psnet.ahrq.gov/issue/correlates-medication-error-hospitals
      August 24, 2022 - Book/Report Correlates of Medication Error in Hospitals. Citation Text: Correlates Of Medication Error In Hospitals. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Save …

2219. Supplementary Advisory: Results of the PA-PSRS Workgroup on Pharmacy Computer System Safety. | PSNet
      psnet.ahrq.gov/issue/supplementary-advisory-results-pa-psrs-workgroup-pharmacy-computer-system-safety
      October 21, 2020 - Government Resource Supplementary Advisory: Results of the PA-PSRS Workgroup on Pharmacy Computer System Safety. Citation Text: Supplementary Advisory: Results of the PA-PSRS Workgroup on Pharmacy Computer System Safety. Patient Safety Advisory Copy Citation Save …

2220. Rudeness at work. | PSNet
      psnet.ahrq.gov/issue/rudeness-work
      May 29, 2014 - Commentary Rudeness at work. Citation Text: Flin R. Rudeness at work. BMJ. 2010;340:c2480. doi:10.1136/bmj.c2480. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Sa…