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221. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
     January 01, 2020 - Source and Credits • This presentation is based on the February 2020 AHRQ WebM&M Spotlight Case ○ See … Diseases clinic, and although follow-up laboratory tests were recommended, they were not drawn. 4 Case … orders included weekly complete blood count, metabolic panel, and vancomycin trough levels. 6 Case … Case 1: OPAT follow-up? (2) Case 2: OPAT follow-up? (1) Case 2: OPAT follow-up? … (2) Case 2: OPAT follow-up?

222. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837972/psn-pdf
     September 01, 2022 - Patient safety: where to aim when zero harm is not the target-a case for learning and resilience. … Patient safety: where to aim when zero harm is not the target-a case for learning and resilience. … https://psnet.ahrq.gov/issue/patient-safety-where-aim-when-zero-harm-not-target-case-learning-and- resilience … https://psnet.ahrq.gov/issue/patient-safety-where-aim-when-zero-harm-not-target-case-learning-and-resilience … https://psnet.ahrq.gov/issue/patient-safety-where-aim-when-zero-harm-not-target-case-learning-and-resilience

223. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44753/psn-pdf
     April 12, 2019 - A vignette study to assess recognition of cognitive biases in clinical case workups. … A vignette study to assess recognition of cognitive biases in clinical case workups. … psnet.ahrq.gov/issue/bias-eye-beholder-vignette-study-assess-recognition-cognitive-biases-clinical- case-workups … /psnet.ahrq.gov/issue/bias-eye-beholder-vignette-study-assess-recognition-cognitive-biases-clinical-case-workups … /psnet.ahrq.gov/issue/bias-eye-beholder-vignette-study-assess-recognition-cognitive-biases-clinical-case-workups

224. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73141/psn-pdf
     April 14, 2021 - Investigating hospital supervision: a case study of regulatory inspectors' roles as potential co-creators … Investigating Hospital Supervision: A Case Study of Regulatory Inspectors’ Roles as Potential Co-creators … https://psnet.ahrq.gov/issue/investigating-hospital-supervision-case-study-regulatory-inspectors-roles … https://psnet.ahrq.gov/issue/investigating-hospital-supervision-case-study-regulatory-inspectors-roles-potential-co … https://psnet.ahrq.gov/issue/investigating-hospital-supervision-case-study-regulatory-inspectors-roles-potential-co

225. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60232/psn-pdf
     April 15, 2020 - Sustaining innovations in complex health care environments: a multiple-case study of rapid response … Sustaining innovations in complex health care environments: a multiple-case study of rapid response … https://psnet.ahrq.gov/issue/sustaining-innovations-complex-health-care-environments-multiple-case-study … https://psnet.ahrq.gov/issue/sustaining-innovations-complex-health-care-environments-multiple-case-study-rapid-response … https://psnet.ahrq.gov/issue/sustaining-innovations-complex-health-care-environments-multiple-case-study-rapid-response

226. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47952/psn-pdf
     January 01, 2020 - Analysis of a case and review of the literature. … Analysis of a case and review of the literature. Acta Clin Belg. 2020;75(3):193-199. … //psnet.ahrq.gov/issue/overlooked-guide-wire-multicomplicated-swiss-cheese-model-example- analysis-case-and-review … https://psnet.ahrq.gov/issue/overlooked-guide-wire-multicomplicated-swiss-cheese-model-example-analysis-case-and-review … https://psnet.ahrq.gov/issue/overlooked-guide-wire-multicomplicated-swiss-cheese-model-example-analysis-case-and-review

227. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60873/psn-pdf
     September 02, 2020 - A case study from a large metropolitan healthcare trust. … A case study from a large metropolitan healthcare trust. … https://psnet.ahrq.gov/issue/what-has-been-impact-covid-19-safety-culture-case-study-large-metropolitan … https://psnet.ahrq.gov/issue/what-has-been-impact-covid-19-safety-culture-case-study-large-metropolitan-teaching-hospital … https://psnet.ahrq.gov/issue/what-has-been-impact-covid-19-safety-culture-case-study-large-metropolitan-teaching-hospital

228. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74077/psn-pdf
     November 17, 2021 - Factors associated with wrong blood in tube errors: an international case series - The BEST collaborative … Factors associated with wrong blood in tube errors: an international case series – The BEST collaborative … https://psnet.ahrq.gov/issue/factors-associated-wrong-blood-tube-errors-international-case-series-best … https://psnet.ahrq.gov/issue/factors-associated-wrong-blood-tube-errors-international-case-series-best-collaborative-study … https://psnet.ahrq.gov/issue/factors-associated-wrong-blood-tube-errors-international-case-series-best-collaborative-study

229. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837693/psn-pdf
     January 01, 2023 - Medication-related medical emergency team activations: a case review study of frequency and preventability … Medication-related Medical Emergency Team activations: a case review study of frequency and preventability … https://psnet.ahrq.gov/issue/medication-related-medical-emergency-team-activations-case-review-study- … https://psnet.ahrq.gov/issue/medication-related-medical-emergency-team-activations-case-review-study-frequency-and … https://psnet.ahrq.gov/issue/medication-related-medical-emergency-team-activations-case-review-study-frequency-and

230. Creating effective quality-improvement collaboratives: a multiple case study. | PSNet
     psnet.ahrq.gov/issue/creating-effective-quality-improvement-collaboratives-multiple-case-study
     December 19, 2012 - Study Creating effective quality-improvement collaboratives: a multiple case study … Creating effective quality-improvement collaboratives: a multiple case study. … Creating effective quality-improvement collaboratives: a multiple case study.

231. Case study: preventing surgical complications at Baystate Medical Center. | PSNet
     psnet.ahrq.gov/issue/case-study-preventing-surgical-complications-baystate-medical-center
     May 27, 2011 - Commentary Case study: preventing surgical complications at Baystate Medical Center … Case Study: Preventing Surgical Complications at Baystate Medical Center. … Case Study: Preventing Surgical Complications at Baystate Medical Center.

232. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44561/psn-pdf
     October 30, 2023 - AHRQ Impact Case Studies: Patient Safety. … https://psnet.ahrq.gov/issue/ahrq-impact-case-studies-patient-safety AHRQ supports the development and … This collection of case studies highlights AHRQ-funded patient safety tools, including the Comprehensive … https://psnet.ahrq.gov/issue/ahrq-impact-case-studies-patient-safety https://psnet.ahrq.gov/issue/cusp-toolkit

233. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60279/psn-pdf
     April 29, 2020 - Exploring challenges in quality and safety work in nursing homes and home care - a case study as basis … Exploring challenges in quality and safety work in nursing homes and home care – a case study as basis … https://psnet.ahrq.gov/issue/exploring-challenges-quality-and-safety-work-nursing-homes-and-home-care- case-study-basis … https://psnet.ahrq.gov/issue/exploring-challenges-quality-and-safety-work-nursing-homes-and-home-care-case-study-basis … https://psnet.ahrq.gov/issue/exploring-challenges-quality-and-safety-work-nursing-homes-and-home-care-case-study-basis

234. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851187/psn-pdf
     July 05, 2023 - Patient and public co-creation of healthcare safety and healthcare system resilience: the case of COVID … creation of healthcare safety and healthcare system resilience: the case of COVID?19. … psnet.ahrq.gov/issue/patient-and-public-co-creation-healthcare-safety-and-healthcare-system- resilience-case-covid … psnet.ahrq.gov/issue/patient-and-public-co-creation-healthcare-safety-and-healthcare-system-resilience-case-covid … psnet.ahrq.gov/issue/patient-and-public-co-creation-healthcare-safety-and-healthcare-system-resilience-case-covid

235. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851158/psn-pdf
     June 28, 2023 - https://psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization The Case … reports published. 10,11 Unfortunately, in this case, the complication was compounded by several key … The multipurpose A (MPA) catheter, in this case, is rarely used except in particular circumstances, … It is unclear if a wire was used to cross the valve in this case, but contrast was injected through the … A case report. Rev Esp Anestesiol Reanim (Engl Ed). 2019;66(10):528-532. [Available at]  4.

236. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50668/psn-pdf
     November 13, 2019 - Case Study Webinar Series on Clinician Burnout: The Ohio State University November 13, 2019 NAM Action … Case Study Webinar Series on Clinician Burnout: The Ohio State University. … https://psnet.ahrq.gov/issue/case-study-webinar-series-clinician-burnout-ohio-state-university Clinician … https://psnet.ahrq.gov/issue/case-study-webinar-series-clinician-burnout-ohio-state-university

237. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50381/psn-pdf
     September 25, 2019 - Error disclosure and apology in radiology: the case for further dialogue. … Error Disclosure and Apology in Radiology: The Case for Further Dialogue. … https://psnet.ahrq.gov/issue/error-disclosure-and-apology-radiology-case-further-dialogue This commentary … https://psnet.ahrq.gov/issue/error-disclosure-and-apology-radiology-case-further-dialogue https://psnet.ahrq.gov

238. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60921/psn-pdf
     September 16, 2020 - How physicians think: a case-based diagnostic simulation exercise. … https://psnet.ahrq.gov/issue/how-physicians-think-case-based-diagnostic-simulation-exercise This article … describes the use of a case-based simulation to explore how physicians reason, create differential … https://psnet.ahrq.gov/issue/how-physicians-think-case-based-diagnostic-simulation-exercise https://psnet.ahrq.gov

239. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48128/psn-pdf
     August 28, 2019 - Burnout in healthcare: the case for organisational change. … Burnout in healthcare: the case for organisational change. … https://psnet.ahrq.gov/issue/burnout-healthcare-case-organisational-change Burnout has been linked to … https://psnet.ahrq.gov/issue/burnout-healthcare-case-organisational-change https://psnet.ahrq.gov/perspective

240. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841482/psn-pdf
     December 14, 2022 - Errors in surgery: a case control study. … Errors in surgery: a case control study. … https://psnet.ahrq.gov/issue/errors-surgery-case-control-study The perioperative period represents a … https://psnet.ahrq.gov/issue/errors-surgery-case-control-study https://psnet.ahrq.gov/issue/influence-perioperative-handoffs-complications-and-outcomes