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  1. Psn-Pdf (pdf file)

    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
  2. Psn-Pdf (pdf file)

    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
  3. Psn-Pdf (pdf file)

    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
  4. Psn-Pdf (pdf file)

    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
  5. Psn-Pdf (pdf file)

    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
  6. 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].
  7. Psn-Pdf (pdf file)

    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
  8. Psn-Pdf (pdf file)

    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
  9. Psn-Pdf (pdf file)

    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
  10. Psn-Pdf (pdf file)

    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
  11. Psn-Pdf (pdf file)

    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://
  12. Psn-Pdf (pdf file)

    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
  13. Psn-Pdf (pdf file)

    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
  14. Psn-Pdf (pdf file)

    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
  15. Psn-Pdf (pdf file)

    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
  16. Psn-Pdf (pdf file)

    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
  17. Psn-Pdf (pdf file)

    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
  18. Psn-Pdf (pdf file)

    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
  19. Psn-Pdf (pdf file)

    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
  20. 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

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