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  1. Compare and Contrast | PSNet

    psnet.ahrq.gov/web-mm/compare-and-contrast
    July 16, 2019 - SPOTLIGHT CASE Compare and Contrast Citation Text: Cho KC, Chertow GM. Compare and Contrast. 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 End…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846170/psn-pdf
    March 15, 2023 - Duplicate Therapies in Retail Pharmacy March 15, 2023 Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy The Cases Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection f…

  3. Tough Call: Addressing Errors From Previous Providers | PSNet

    psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
    July 17, 2024 - SPOTLIGHT CASE Tough Call: Addressing Errors From Previous Providers Citation Text: Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy…

  4. Duplicate Insulin Order | PSNet

    psnet.ahrq.gov/web-mm/duplicate-insulin-order
    May 04, 2012 - Duplicate Insulin Order Citation Text: Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. 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 Endn…

  5. Novel Drug Misuse | PSNet

    psnet.ahrq.gov/web-mm/novel-drug-misuse
    September 30, 2010 - SPOTLIGHT CASE Novel Drug Misuse Citation Text: Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

  6. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. | PSNet

    psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
    October 31, 2023 - SPOTLIGHT CASE Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. Citation Text: Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…

  7. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. | PSNet

    psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
    August 25, 2021 - SPOTLIGHT CASE Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. Citation Text: Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …

  8. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. | PSNet

    psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
    March 19, 2019 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. Citation Text: Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…

  9. Estimating breast cancer overdiagnosis after screening mammography among older women in the United States. | PSNet

    psnet.ahrq.gov/issue/estimating-breast-cancer-overdiagnosis-after-screening-mammography-among-older-women-united
    October 19, 2022 - Study Estimating breast cancer overdiagnosis after screening mammography among older women in the United States. Citation Text: Richman IB, Long JB, Soulos PR, et al. Estimating breast cancer overdiagnosis after screening mammography among older women in the United States. Ann Intern Med…

  10. Patient, provider, and system factors contributing to patient safety events during medical and surgical hospitalizations for persons with serious mental illness. | PSNet

    psnet.ahrq.gov/issue/patient-provider-and-system-factors-contributing-patient-safety-events-during-medical-and
    November 18, 2016 - Study Patient, provider, and system factors contributing to patient safety events during medical and surgical hospitalizations for persons with serious mental illness. Citation Text: McGinty EE, Thompson DA, Pronovost P, et al. Patient, provider, and system factors contributing to patien…

  11. Fifteen years after To Err Is Human: a success story to learn from. | PSNet

    psnet.ahrq.gov/issue/fifteen-years-after-err-human-success-story-learn
    August 04, 2021 - Commentary Fifteen years after To Err Is Human: a success story to learn from. Citation Text: Pronovost P, Cleeman JI, Wright D, et al. Fifteen years after To Err is Human: a success story to learn from. BMJ Qual Saf. 2016;25(6):396-9. doi:10.1136/bmjqs-2015-004720. Copy Citation F…

  12. The host hospital 24-hour underreferral rate: an automated measure of call-center safety. | PSNet

    psnet.ahrq.gov/issue/host-hospital-24-hour-underreferral-rate-automated-measure-call-center-safety
    September 23, 2020 - Study The host hospital 24-hour underreferral rate: an automated measure of call-center safety. Citation Text: Hirsh DA, Simon HK, Massey R, et al. The host hospital 24-hour underreferral rate: an automated measure of call-center safety. Pediatrics. 2007;119(6):1139-1144. Copy Citati…

  13. Effect of distractions on operative performance and ability to multitask—a case for deliberate practice. | PSNet

    psnet.ahrq.gov/issue/effect-distractions-operative-performance-and-ability-multitask-case-deliberate-practice
    September 15, 2010 - Study Effect of distractions on operative performance and ability to multitask—a case for deliberate practice. Citation Text: Ahmed A, Ahmad M, Stewart M, et al. Effect of distractions on operative performance and ability to multitask--a case for deliberate practice. Laryngoscope. 2015;1…

  14. Reducing cardiopulmonary arrest rates in a three-year regional rapid response system collaborative. | PSNet

    psnet.ahrq.gov/issue/reducing-cardiopulmonary-arrest-rates-three-year-regional-rapid-response-system-collaborative
    March 04, 2011 - Study Reducing cardiopulmonary arrest rates in a three-year regional rapid response system collaborative. Citation Text: Rosen MJ, Hoberman AJ, Ruiz RE, et al. Reducing cardiopulmonary arrest rates in a three-year regional rapid response system collaborative. Jt Comm J Qual Patient Saf…

  15. Variability in the measurement of hospital-wide mortality rates. | PSNet

    psnet.ahrq.gov/issue/variability-measurement-hospital-wide-mortality-rates
    July 01, 2016 - Study Classic Variability in the measurement of hospital-wide mortality rates. Citation Text: Shahian DM, Wolf RE, Iezzoni LI, et al. Variability in the measurement of hospital-wide mortality rates. N Engl J Med. 2010;363(26):2530-9. doi:10.1056/NEJMsa1006396. …

  16. Effect of using the same vs different order for second readings of screening mammograms on rates of breast cancer detection: a randomized clinical trial. | PSNet

    psnet.ahrq.gov/issue/effect-using-same-vs-different-order-second-readings-screening-mammograms-rates-breast-cancer
    August 29, 2018 - Study Effect of using the same vs different order for second readings of screening mammograms on rates of breast cancer detection: a randomized clinical trial. Citation Text: Taylor-Phillips S, Wallis MG, Jenkinson D, et al. Effect of Using the Same vs Different Order for Second Readings…

  17. Retained guidewires in the Veterans Health Administration: getting to the root of the problem. | PSNet

    psnet.ahrq.gov/issue/retained-guidewires-veterans-health-administration-getting-root-problem
    March 13, 2013 - Study Retained guidewires in the Veterans Health Administration: getting to the root of the problem. Citation Text: Cherara L, Sculli GL, Paull DE, et al. Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem. J Patient Saf. 2021;17(8):e991-e928. d…

  18. A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers. | PSNet

    psnet.ahrq.gov/issue/prospective-observational-study-physician-handoff-intensive-care-unit-ward-patient-transfers
    October 08, 2013 - Study A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers. Citation Text: Li P, Stelfox HT, Ghali WA. A Prospective Observational Study of Physician Handoff for Intensive-Care-Unit-to-Ward Patient Transfers. Am J Med. 2011;124(9). do…

  19. How differences between manager and clinician perceptions of safety culture impact hospital processes of care. | PSNet

    psnet.ahrq.gov/issue/how-differences-between-manager-and-clinician-perceptions-safety-culture-impact-hospital
    December 21, 2018 - Study How differences between manager and clinician perceptions of safety culture impact hospital processes of care. Citation Text: Richter J, Mazurenko O, Kazley AS, et al. How Differences Between Manager and Clinician Perceptions of Safety Culture Impact Hospital Processes of Care. J P…

  20. An educational intervention to enhance nurse leaders' perceptions of patient safety culture. | PSNet

    psnet.ahrq.gov/issue/educational-intervention-enhance-nurse-leaders-perceptions-patient-safety-culture
    February 14, 2015 - Study An educational intervention to enhance nurse leaders' perceptions of patient safety culture. Citation Text: Ginsburg LR, Norton PG, Casebeer A, et al. An educational intervention to enhance nurse leaders' perceptions of patient safety culture. Health Serv Res. 2005;40(4):997-1020…
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