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psnet.ahrq.gov/node/865927/psn-pdf
May 22, 2024 - Organizational learning starting points and
presuppositions: a case study from a hospital’s surgical … Organizational learning starting points and presuppositions: a case
study from a hospital’s surgical … https://psnet.ahrq.gov/issue/organizational-learning-starting-points-and-presuppositions-case-study- … https://psnet.ahrq.gov/issue/organizational-learning-starting-points-and-presuppositions-case-study-hospitals-surgical … https://psnet.ahrq.gov/issue/organizational-learning-starting-points-and-presuppositions-case-study-hospitals-surgical
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psnet.ahrq.gov/node/865870/psn-pdf
May 15, 2024 - Leading quality and safety on the frontline - a case study
of department leaders in nursing homes. … Leading quality and safety on the frontline - a case study of
department leaders in nursing homes. … https://psnet.ahrq.gov/issue/leading-quality-and-safety-frontline-case-study-department-leaders-nursing … https://psnet.ahrq.gov/issue/leading-quality-and-safety-frontline-case-study-department-leaders-nursing-homes … https://psnet.ahrq.gov/issue/leading-quality-and-safety-frontline-case-study-department-leaders-nursing-homes
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psnet.ahrq.gov/node/50759/psn-pdf
December 18, 2019 - The lurking danger in the “business case” for patient
safety
December 18, 2019
Millenson ML. … https://psnet.ahrq.gov/issue/lurking-danger-business-case-patient-safety
The two decades since To Err … unintended consequences of the financial
drivers to motivate improvement and the drive to define a business case … https://psnet.ahrq.gov/issue/lurking-danger-business-case-patient-safety
https://psnet.ahrq.gov/issue … relationship-between-occurrence-surgical-complications-and-hospital-finances
https://psnet.ahrq.gov/issue/making-business-case-patient-safety
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psnet.ahrq.gov/node/861286/psn-pdf
January 24, 2024 - Surgical safety does not happen by accident: learning
from perioperative near miss case studies. … Surgical safety does not happen by accident: learning
from perioperative near miss case studies. … ://psnet.ahrq.gov/issue/surgical-safety-does-not-happen-accident-learning-perioperative-near-miss-
case-studies … https://psnet.ahrq.gov/issue/surgical-safety-does-not-happen-accident-learning-perioperative-near-miss-case-studies … https://psnet.ahrq.gov/issue/surgical-safety-does-not-happen-accident-learning-perioperative-near-miss-case-studies
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psnet.ahrq.gov/node/848827/psn-pdf
May 10, 2023 - TQIP Mortality Reporting System Case Reports. … https://psnet.ahrq.gov/issue/tqip-mortality-reporting-system-case-reports
Anonymous case reporting provides … This case series shares analysis of adverse events
submitted to a trauma center-focused reporting program … https://psnet.ahrq.gov/issue/tqip-mortality-reporting-system-case-reports
https://psnet.ahrq.gov/primer
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - SPOTLIGHT CASE
Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery … Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. … Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. … The Case A 77-year-old man was admitted to the hospital with acute chest pain and shortness of breath … Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet].
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psnet.ahrq.gov/node/60562/psn-pdf
June 03, 2020 - A case-controlled study of relatives' complaints
concerning patients who died in hospital: the role … A case-controlled study of relatives’ complaints concerning
patients who died in hospital: the role … https://psnet.ahrq.gov/issue/case-controlled-study-relatives-complaints-concerning-patients-who-died- … This retrospective case-control study set
in three UK hospitals explored whether the use of TELPs was … https://psnet.ahrq.gov/issue/case-controlled-study-relatives-complaints-concerning-patients-who-died-hospital-role
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psnet.ahrq.gov/node/74052/psn-pdf
November 10, 2021 - When disasters strike the emergency department: a case
series and narrative review. … When disasters strike the emergency department: a case series
and narrative review. … https://psnet.ahrq.gov/issue/when-disasters-strike-emergency-department-case-series-and-narrative-review … This case series and
review focus on internal disasters in emergency departments (e.g., structural damage … https://psnet.ahrq.gov/issue/when-disasters-strike-emergency-department-case-series-and-narrative-review
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psnet.ahrq.gov/node/856590/psn-pdf
November 29, 2023 - Team experiences of the root cause analysis process
after a sentinel event: a qualitative case study … Team experiences of the root cause analysis process after a sentinel
event: a qualitative case study … psnet.ahrq.gov/issue/team-experiences-root-cause-analysis-process-after-sentinel-event-qualitative-
case-study … /psnet.ahrq.gov/issue/team-experiences-root-cause-analysis-process-after-sentinel-event-qualitative-case-study … /psnet.ahrq.gov/issue/team-experiences-root-cause-analysis-process-after-sentinel-event-qualitative-case-study
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psnet.ahrq.gov/node/840169/psn-pdf
November 16, 2022 - ISMP survey on tall man (mixed case) lettering to reduce
drug name confusion. … https://psnet.ahrq.gov/issue/ismp-survey-tall-man-mixed-case-lettering-reduce-drug-name-confusion
Mixed … case letters are one suggested strategy to reduce look-alike medication name errors. … update an existing resource of problematic drug name pairs
and examine the effectiveness of mixed case … https://psnet.ahrq.gov/issue/ismp-survey-tall-man-mixed-case-lettering-reduce-drug-name-confusion
https
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psnet.ahrq.gov/node/860719/psn-pdf
January 17, 2024 - Diagnostic accuracy of a large language model in
pediatric case studies. … Diagnostic accuracy of a large language model in pediatric case
studies. … https://psnet.ahrq.gov/issue/diagnostic-accuracy-large-language-model-pediatric-case-studies
Clinicians … study asked ChatGPT to provide a differential diagnosis list and
final diagnosis for 100 pediatric case … https://psnet.ahrq.gov/issue/diagnostic-accuracy-large-language-model-pediatric-case-studies
https://
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psnet.ahrq.gov/node/853624/psn-pdf
September 20, 2023 - Do malpractice claim clinical case vignettes enhance
diagnostic accuracy and acceptance in clinical … Do malpractice claim clinical case vignettes enhance diagnostic
accuracy and acceptance in clinical … https://psnet.ahrq.gov/issue/do-malpractice-claim-clinical-case-vignettes-enhance-diagnostic-accuracy … https://psnet.ahrq.gov/issue/do-malpractice-claim-clinical-case-vignettes-enhance-diagnostic-accuracy-and-acceptance … https://psnet.ahrq.gov/issue/do-malpractice-claim-clinical-case-vignettes-enhance-diagnostic-accuracy-and-acceptance
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psnet.ahrq.gov/node/47731/psn-pdf
April 27, 2019 - Implementing strategies to identify and mitigate adverse
safety events: a case study with unplanned … Implementing Strategies to Identify and Mitigate Adverse Safety Events:
A Case Study with Unplanned … https://psnet.ahrq.gov/issue/implementing-strategies-identify-and-mitigate-adverse-safety-events-case … https://psnet.ahrq.gov/issue/implementing-strategies-identify-and-mitigate-adverse-safety-events-case-study-unplanned … https://psnet.ahrq.gov/issue/implementing-strategies-identify-and-mitigate-adverse-safety-events-case-study-unplanned
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psnet.ahrq.gov/node/60943/psn-pdf
September 23, 2020 - Think twice: effects on diagnostic accuracy of returning
to the case to reflect upon the initial diagnosis … Think twice: effects on diagnostic accuracy of returning to the
case to reflect upon the initial diagnosis … https://psnet.ahrq.gov/issue/think-twice-effects-diagnostic-accuracy-returning-case-reflect-upon-initial … https://psnet.ahrq.gov/issue/think-twice-effects-diagnostic-accuracy-returning-case-reflect-upon-initial-diagnosis … https://psnet.ahrq.gov/issue/think-twice-effects-diagnostic-accuracy-returning-case-reflect-upon-initial-diagnosis
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psnet.ahrq.gov/node/46065/psn-pdf
January 01, 2021 - Measurement as a performance driver: the case for a
national measurement system to improve patient safety … Measurement as a Performance Driver: The Case for a National
Measurement System to Improve Patient Safety … https://psnet.ahrq.gov/issue/measurement-performance-driver-case-national-measurement-system-
improve-patient-safety … https://psnet.ahrq.gov/issue/measurement-performance-driver-case-national-measurement-system-improve-patient-safety … https://psnet.ahrq.gov/issue/measurement-performance-driver-case-national-measurement-system-improve-patient-safety
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psnet.ahrq.gov/node/47923/psn-pdf
April 17, 2019 - Improving employee voice about transgressive or
disruptive behavior: a case study. … Improving Employee Voice About Transgressive or Disruptive
Behavior: A Case Study. … https://psnet.ahrq.gov/issue/improving-employee-voice-about-transgressive-or-disruptive-behavior-case … https://psnet.ahrq.gov/issue/improving-employee-voice-about-transgressive-or-disruptive-behavior-case-study … https://psnet.ahrq.gov/issue/improving-employee-voice-about-transgressive-or-disruptive-behavior-case-study
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psnet.ahrq.gov/node/46772/psn-pdf
March 04, 2019 - Case: a second victim support program in pediatrics:
successes and challenges to implementation. … Case: A Second Victim Support Program in Pediatrics:
Successes and Challenges to Implementation. … https://psnet.ahrq.gov/issue/case-second-victim-support-program-pediatrics-successes-and-challenges- … https://psnet.ahrq.gov/issue/case-second-victim-support-program-pediatrics-successes-and-challenges-implementation … https://psnet.ahrq.gov/issue/case-second-victim-support-program-pediatrics-successes-and-challenges-implementation
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psnet.ahrq.gov/node/848043/psn-pdf
April 26, 2023 - Tools for establishing a sustainable safety culture within
maternity services: a retrospective case … Tools for establishing a sustainable safety culture within
maternity services: a retrospective case … psnet.ahrq.gov/issue/tools-establishing-sustainable-safety-culture-within-maternity-services-
retrospective-case … psnet.ahrq.gov/issue/tools-establishing-sustainable-safety-culture-within-maternity-services-retrospective-case … psnet.ahrq.gov/issue/tools-establishing-sustainable-safety-culture-within-maternity-services-retrospective-case
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psnet.ahrq.gov/node/72700/psn-pdf
January 01, 2022 - Missed acute coronary syndrome during telephone triage
at out-of-hours primary care: lessons from a case-control … psnet.ahrq.gov/issue/missed-acute-coronary-syndrome-during-telephone-triage-out-hours-primary-
care-lessons-case … This case-
control study compared missed acute coronary syndrome (ACS) cases to other cases with chest … psnet.ahrq.gov/issue/missed-acute-coronary-syndrome-during-telephone-triage-out-hours-primary-care-lessons-case … psnet.ahrq.gov/issue/missed-acute-coronary-syndrome-during-telephone-triage-out-hours-primary-care-lessons-case
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psnet.ahrq.gov/print/pdf/node/840940
March 22, 2024 - innovations-video
https://psnet.ahrq.gov/personalization
https://psnet.ahrq.gov/shared-libraries
The Submit a Case … Process
March 22, 2024
The Submit a Case Process PSNet’s Submit a Case feature allows health care professionals … Watch the video below to learn more about the Submit a Case process. … Submit Your
Case Audio-Described Version (1 minute, 39 seconds)
Introducing Curated Libraries
March … Visit Curated Libraries Audio-Described Version (1
minute, 58 seconds)
https://psnet.ahrq.gov/submit-case