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  1. psnet.ahrq.gov/issue/malpractice-cases-breast-surgery-assessment-litigation-involving-surgeons
    August 04, 2021 - Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author
  2. psnet.ahrq.gov/issue/toward-theory-self-reconciliation-following-mistakes-nursing-practice
    December 22, 2008 - Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author … December 15, 2014 Work-arounds observed by fourth-year nursing students.
  3. psnet.ahrq.gov/issue/surgical-site-signing-and-time-out-issues-compliance-or-complacence
    January 07, 2011 - Adherence to measures to prevent wrong-site surgery remained lower than optimal over a 2-year period … Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author
  4. psnet.ahrq.gov/web-mm/emergency-error
    January 18, 2013 - The Case An 81-year-old woman with a history of pancreatitis presented with the acute onset of abdominal … Improvement Program (NSQIP) database (including more than 470,000 procedures at 198 hospitals over a 4-year … medical staff that their performance was being observed had little effect, but issuing staff a job description … Poor 1-year survival in elderly patients undergoing nonelective colorectal resection. … The Case The Commentary References Figure Related Resources From the Same Author
  5. psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
    August 01, 2019 - There is no standard job description for scribes. … (such as a nursing practitioner) consistent with the roles and responsibilities defined in the job description … Edwin Smith papyrus: 3,600-year-old surgical treatise reveals secrets of ancient Egyptian medical knowledge … RW : Do you have a sense of how much we as a health system are spending on this each year and what the … Know About Scribes Moving Forward References Related Resources From the Same Author
  6. psnet.ahrq.gov/issue/radiology-impact-healthcare-errors-during-shift-work
    February 24, 2021 - Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author … June 16, 2021 Oncologic errors in diagnostic radiology: a 10-year analysis based on medical
  7. psnet.ahrq.gov/web-mm/discharging-our-responsibility
    January 16, 2019 - The Case A 75-year-old man with a history of hypertension, coronary artery disease, and congestive … 3.6 million hospitalizations attributed to HF as the primary or secondary discharge diagnosis each year … Over the 2-year study period, the discharge instruction HF performance measure improved significantly … Performance Measure Name Measure Description Discharge instructions Heart failure patients … The Case The Commentary References Table Related Resources From the Same Author
  8. psnet.ahrq.gov/issue/medicolegal-aspect-error-pathology-search-jury-verdicts-and-settlements
    February 04, 2016 - Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author … December 18, 2017 Comparison of clinical diagnoses and autopsy findings: six-year retrospective
  9. psnet.ahrq.gov/issue/patient-safety-and-professional-discourses-implications-interprofessionalism
    March 08, 2023 - Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author … March 21, 2018 Four-year impact of an alert notification system on closed-loop communication
  10. psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
    March 27, 2024 - Updates include increased use by other organizations, slight modifications to the description of the … $1,100-$1,450 lower per year compared to their non-SASH peers. … Description of the Innovative Activity The Support and Services at Home (SASH) program, administered … a year later). … implementation (30 resident falls the year before implementation, 16 resident falls a year later).
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860049/psn-pdf
    January 04, 2024 - psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient The Case A 9-year-old … This phrase serves the same notational purpose as “continue to monitor”; it provides the author cognitive … results were not yet available at the time of transfer, that handoff should have included a clear description … of discharge, the primary care physician and outpatient neurologist would have only the narrative description … discharge summary template so that it begins with “Important Comments to Subsequent Providers” before the description
  12. psnet.ahrq.gov/issue/handoff-practices-undergraduate-medical-education
    June 07, 2023 - even though 93% reported that medical students routinely perform handoff activities in their final year … Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author
  13. psnet.ahrq.gov/issue/analysis-hospital-readmission-rates-after-implementation-hospital-readmissions-reduction
    October 12, 2022 - Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author … October 12, 2022 A 6-year thematic review of reported incidents associated with cardiopulmonary
  14. psnet.ahrq.gov/perspective/diagnostic-errors
    December 01, 2013 - than 12 million individuals) experience a serious diagnostic error in the outpatient setting every year … complex, and so that the salient distracting feature appeared either near the beginning of the case description … especially for complex cases, but only when the distractor appeared near the beginning of the case description … So while I was a junior investigator, if there was an opportunity to write a first author paper on a … Sections Annual Perspective 2014 Related Resources From the Same Author
  15. psnet.ahrq.gov/issue/antiretroviral-medication-errors-national-medication-error-database
    January 06, 2017 - Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author … January 5, 2017 Harmful medication errors in children: a 5-year analysis of data from
  16. psnet.ahrq.gov/issue/operating-room-organization-and-surgical-performance-systematic-review
    March 05, 2025 - Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author … November 15, 2023 Understanding ultrarare adverse events - lessons learned from a twelve-year
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49427/psn-pdf
    January 01, 2004 - https://psnet.ahrq.gov/web-mm/inadvertent-castration The Case An 83-year-old man presented with a left … Accident Investigation The case description contains insufficient information to identify the specific … Decision Support From my reading of the case description, I've inferred that the orchiectomy was probably
  18. psnet.ahrq.gov/issue/effective-strategies-increase-reporting-medication-errors-hospitals
    October 19, 2010 - Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author … (s) Nonpunitive medication error reporting: 3-year findings from one hospital's primum
  19. psnet.ahrq.gov/issue/innovation-patient-safety-new-task-design-reducing-patient-falls
    January 04, 2010 - Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author … June 22, 2009 Sustaining the gains: a 7-year follow-through of a hospital-wide patient … hospital-wide clinical laboratory specimen identification errors following process interventions: a 10-year
  20. psnet.ahrq.gov/issue/factors-drive-team-participation-surgical-safety-checks-prospective-study
    August 15, 2018 - Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author … of the WHO surgical safety checklist combined with pulse oximetry in a resource-limited setting: two-year

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