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241. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41166/psn-pdf
     February 29, 2012 - Triangulating case-finding tools for patient safety surveillance: a cross-sectional case study of puncture … Triangulating case-finding tools for patient safety surveillance: a cross-sectional case study of puncture … - case-study This study found that four existing case detection tools, including the AHRQ Patient Safety … https://psnet.ahrq.gov/issue/triangulating-case-finding-tools-patient-safety-surveillance-cross-sectional-case-study … https://psnet.ahrq.gov/issue/triangulating-case-finding-tools-patient-safety-surveillance-cross-sectional-case-study

242. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34796/psn-pdf
     November 18, 2015 - The business case for quality: case studies and an analysis. … The business case for quality: case studies and an analysis. … https://psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis This comprehensive review … The authors examine four case studies to explore the financial and clinical implications of quality … https://psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis

243. Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes. | PSNet
     psnet.ahrq.gov/issue/misdiagnosis-analysis-based-case-record-review-proposals-aimed-improve-diagnostic-processes
     November 12, 2014 - Study Misdiagnosis: analysis based on case record review with proposals aimed to … Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes … Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes … Related Resources From the Same Author(s) Learning from preventable deaths: exploring case … Preventable deaths due to problems in care in English acute hospitals: a retrospective case

244. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46871/psn-pdf
     July 14, 2018 - case review of closed ED malpractice claims. … Understanding diagnostic safety in emergency medicine: A case- by-case review of closed ED malpractice … https://psnet.ahrq.gov/issue/understanding-diagnostic-safety-emergency-medicine-case-case-review- closed-ed-malpractice … https://psnet.ahrq.gov/issue/understanding-diagnostic-safety-emergency-medicine-case-case-review-closed-ed-malpractice … https://psnet.ahrq.gov/issue/understanding-diagnostic-safety-emergency-medicine-case-case-review-closed-ed-malpractice

245. Increased mortality associated with weekend hospital admission: a case for expanded seven day services? | PSNet
     psnet.ahrq.gov/issue/increased-mortality-associated-weekend-hospital-admission-case-expanded-seven-day-services
     March 02, 2012 - Study Increased mortality associated with weekend hospital admission: a case for … Increased mortality associated with weekend hospital admission: a case for expanded seven day services … Increased mortality associated with weekend hospital admission: a case for expanded seven day services … April 6, 2016 Organizational ambidexterity and the hybrid middle manager: the case of … November 25, 2015 Exploring the role of communications in quality improvement: a case

246. Patient safety: it's not just carefulness, it's a culture. | PSNet
     psnet.ahrq.gov/issue/patient-safety-its-not-just-carefulness-its-culture
     December 24, 2008 - Lippincotts Case Manag. 2004;9(5):211-212. doi:10.1097/00129234-200409000-00001. … Lippincotts Case Manag . 2004; 9 (5) :211-212 . … Lippincotts Case Manag. 2004;9(5):211-212. doi:10.1097/00129234-200409000-00001. … A case study from a large metropolitan healthcare trust. … March 30, 2022 The business case for patient safety.

247. Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. | PSNet
     psnet.ahrq.gov/issue/learning-preventable-deaths-exploring-case-record-reviewers-narratives-using-change-analysis
     June 17, 2014 - Study Learning from preventable deaths: exploring case record reviewers' narratives … Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. … Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. … Preventable deaths due to problems in care in English acute hospitals: a retrospective case … April 5, 2013 Misdiagnosis: analysis based on case record review with proposals aimed

248. Organizational ambidexterity and the hybrid middle manager: the case of patient safety in UK hospitals. | PSNet
     psnet.ahrq.gov/issue/organizational-ambidexterity-and-hybrid-middle-manager-case-patient-safety-uk-hospitals
     January 29, 2014 - Study Organizational ambidexterity and the hybrid middle manager: the case of patient … Organizational Ambidexterity and the Hybrid Middle Manager: The Case of Patient Safety in UK Hospitals … Organizational Ambidexterity and the Hybrid Middle Manager: The Case of Patient Safety in UK Hospitals … , 2014 The limits of knowledge management for UK public services modernization: the case … June 21, 2016 Exploring the role of communications in quality improvement: a case study

249. Nurse staffing in hospitals: is there a business case for quality? | PSNet
     psnet.ahrq.gov/issue/nurse-staffing-hospitals-there-business-case-quality
     February 18, 2011 - Classic Nurse staffing in hospitals: is there a business case … Nurse staffing in hospitals: is there a business case for quality? … Nurse staffing in hospitals: is there a business case for quality?

250. Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis. | PSNet
     psnet.ahrq.gov/issue/avoidability-hospital-deaths-and-association-hospital-wide-mortality-ratios-retrospective
     November 12, 2014 - Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case … Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case … Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case … Related Resources From the Same Author(s) Learning from preventable deaths: exploring case … May 19, 2021 Misdiagnosis: analysis based on case record review with proposals aimed

251. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45225/psn-pdf
     June 15, 2016 - A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional … A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional … J Investig Med High Impact Case Rep. 2016;4(2):2324709616647746. doi:10.1177/2324709616647746. … https://psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading … This case analysis discusses a wrong-patient transfusion error in a hospital's emergency room and reviews

252. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35496/psn-pdf
     February 22, 2010 - Safe use of cellular telephones in hospitals: fundamental principles and case studies. … Safe use of cellular telephones in hospitals: fundamental principles and case studies. … https://psnet.ahrq.gov/issue/safe-use-cellular-telephones-hospitals-fundamental-principles-and-case- … studies After reviewing the literature and several case studies, the authors conclude that cell phones … https://psnet.ahrq.gov/issue/safe-use-cellular-telephones-hospitals-fundamental-principles-and-case-studies

253. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41676/psn-pdf
     September 24, 2016 - Taking a detour: positive and negative effects of supervisors' interruptions during admission case review … Taking a detour: positive and negative effects of supervisors' interruptions during admission case review … psnet.ahrq.gov/issue/taking-detour-positive-and-negative-effects-supervisors-interruptions-during- admission-case … Although interrupting learners' admission case presentations may provide valuable opportunities for … psnet.ahrq.gov/issue/taking-detour-positive-and-negative-effects-supervisors-interruptions-during-admission-case

254. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35752/psn-pdf
     December 23, 2012 - A case of cascade iatrogenesis. December 23, 2012 Hofer TP, Hayward RA. … A case of cascade iatrogenesis. Ann Intern Med. 2002;137(5 Part 1):327-333. … /psnet.ahrq.gov/issue/are-bad-outcomes-questionable-clinical-decisions-preventable-medical-errors- case-cascade … The authors present the case of a patient with multiple medical problems who suffers complications … The case is used as background for exploration of the concept of errors, defining preventable ones,

255. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40744/psn-pdf
     October 16, 2012 - The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in … The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in … https://psnet.ahrq.gov/issue/business-case-quality-economic-analysis-michigan-keystone-patient-safety … Substantiating the business case for quality in this fashion will further stimulate wide dissemination … https://psnet.ahrq.gov/issue/business-case-quality-economic-analysis-michigan-keystone-patient-safety-program-icus

256. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35529/psn-pdf
     May 27, 2011 - Case study: identifying potential problems at the human/technical interface in complex clinical systems … Case study: identifying potential problems at the human/technical interface in complex clinical systems … https://psnet.ahrq.gov/issue/case-study-identifying-potential-problems-humantechnical-interface-complex … - clinical-systems The authors present a case study to illustrate system vulnerabilities related to … https://psnet.ahrq.gov/issue/case-study-identifying-potential-problems-humantechnical-interface-complex-clinical-systems

257. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42369/psn-pdf
     September 19, 2013 - Patient safety in healthcare preregistration educational curricula: multiple case study-based investigations … Patient safety in healthcare preregistration educational curricula: multiple case study-based investigations … https://psnet.ahrq.gov/issue/patient-safety-healthcare-preregistration-educational-curricula-multiple-case … - study-based This qualitative case study explored patient safety education across health care professional … https://psnet.ahrq.gov/issue/patient-safety-healthcare-preregistration-educational-curricula-multiple-case-study-based

258. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40020/psn-pdf
     September 20, 2011 - Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand. … Case records of The Massachusetts General Hospital: Case 34-2010: a 65-year-old woman with an incorrect … https://psnet.ahrq.gov/issue/case-34-2010-65-year-old-woman-incorrect-operation-left-hand The Case Records … In contrast to the usual clinical focus, this article discusses a never event—a case of a patient who … https://psnet.ahrq.gov/issue/case-34-2010-65-year-old-woman-incorrect-operation-left-hand https://psnet.ahrq.gov

259. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41081/psn-pdf
     February 01, 2012 - Workarounds in the use of IS in healthcare: a case study of an electronic medication administration … Workarounds in the use of IS in healthcare: A case study of an electronic medication administration … https://psnet.ahrq.gov/issue/workarounds-use-healthcare-case-study-electronic-medication-administration … - system This case study of electronic medical record implementation at a public hospital provides … https://psnet.ahrq.gov/issue/workarounds-use-healthcare-case-study-electronic-medication-administration-system

260. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38942/psn-pdf
     November 25, 2009 - Using in situ simulation to identify and resolve latent environmental threats to patient safety: case … Using in situ simulation to identify and resolve latent environmental threats to patient safety: case … psnet.ahrq.gov/issue/using-situ-simulation-identify-and-resolve-latent-environmental-threats-patient- safety-case … This case analysis explains how crew resource management training provides an opportunity to identify … psnet.ahrq.gov/issue/using-situ-simulation-identify-and-resolve-latent-environmental-threats-patient-safety-case