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psnet.ahrq.gov/node/42698/psn-pdf
December 04, 2013 - A structured judgement method to enhance mortality
case note review: development and evaluation. … A structured judgement method to enhance mortality case note
review: development and evaluation. … https://psnet.ahrq.gov/issue/structured-judgement-method-enhance-mortality-case-note-review-
development-and-evaluation … According to this study, retrospective case note review using a structured approach and a standardized … https://psnet.ahrq.gov/issue/structured-judgement-method-enhance-mortality-case-note-review-development-and-evaluation
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psnet.ahrq.gov/node/39541/psn-pdf
June 02, 2010 - Structured communication for patient safety in
emergency medical services: a legal case report. … Structured communication for patient safety in emergency medical services:
a legal case report. … https://psnet.ahrq.gov/issue/structured-communication-patient-safety-emergency-medical-services-legal-
case-report … This article describes a case where lack of clarity in communication contributed to the death of a … https://psnet.ahrq.gov/issue/structured-communication-patient-safety-emergency-medical-services-legal-case-report
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psnet.ahrq.gov/node/44745/psn-pdf
February 17, 2016 - Implications of case managers' perceptions and attitude
on safety of home-delivered care. … Implications of case managers' perceptions and attitude on safety of home-delivered care. … https://psnet.ahrq.gov/issue/implications-case-managers-perceptions-and-attitude-safety-home-delivered … -
care
This study explores comments collected from focus groups of case management nurses regarding … https://psnet.ahrq.gov/issue/implications-case-managers-perceptions-and-attitude-safety-home-delivered-care
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psnet.ahrq.gov/node/33933/psn-pdf
March 02, 2011 - Patient safety and medical malpractice: a case study.
March 2, 2011
Brennan TA, Mello MM. … Patient safety and medical malpractice: a case study. Ann Intern Med.
2003;139(4):267-73. … https://psnet.ahrq.gov/issue/patient-safety-and-medical-malpractice-case-study
This case study discusses … defendant-physician and her attorney share their perspectives through the
presentation of a specific case … https://psnet.ahrq.gov/issue/patient-safety-and-medical-malpractice-case-study
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psnet.ahrq.gov/node/40009/psn-pdf
November 26, 2014 - Measuring faculty reflection on adverse patient events:
development and initial validation of a case-based … Measuring faculty reflection on adverse patient events:
development and initial validation of a case-based … psnet.ahrq.gov/issue/measuring-faculty-reflection-adverse-patient-events-development-and-initial-
validation-case … This study describes the development and pilot testing of a case-based system to encourage and
measure … psnet.ahrq.gov/issue/measuring-faculty-reflection-adverse-patient-events-development-and-initial-validation-case
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psnet.ahrq.gov/node/45046/psn-pdf
July 05, 2016 - Diagnosing sepsis is subjective and highly variable: a
survey of intensivists using case vignettes. … Diagnosing sepsis is subjective and highly variable: a survey of
intensivists using case vignettes. … //psnet.ahrq.gov/issue/diagnosing-sepsis-subjective-and-highly-variable-survey-intensivists-using-
case-vignettes … Using
case vignettes, this survey of intensivists found substantial variation in accurately diagnosing … https://psnet.ahrq.gov/issue/diagnosing-sepsis-subjective-and-highly-variable-survey-intensivists-using-case-vignettes
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psnet.ahrq.gov/node/42806/psn-pdf
January 19, 2014 - Case studies of patient safety research classics to build
research capacity in low- and middle-income … Case studies of patient safety research classics to build research
capacity in low- and middle-income … https://psnet.ahrq.gov/issue/case-studies-patient-safety-research-classics-build-research-capacity-low-and … safety research publications along with
comments by their lead authors to serve as engaging didactic case … https://psnet.ahrq.gov/issue/case-studies-patient-safety-research-classics-build-research-capacity-low-and-middle-income
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psnet.ahrq.gov/node/45383/psn-pdf
August 31, 2016 - Case report of a medication error: in the eye of the
beholder. … Case report of a medication error. … https://psnet.ahrq.gov/issue/case-report-medication-error-eye-beholder
Look-alike drug names or packaging … This case discussion
reviews an error in the community setting involving a nonocular medication mistakenly … https://psnet.ahrq.gov/issue/case-report-medication-error-eye-beholder
https://psnet.ahrq.gov/issue/drug-labeling-and-packaging-looking-beyond-what-meets-eye
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psnet.ahrq.gov/node/33890/psn-pdf
January 04, 2017 - The faces of errors: a case-based approach to educating
providers, policy makers, and the public about … The faces of errors: a case-based approach to educating providers,
policymakers, and the public about … https://psnet.ahrq.gov/issue/faces-errors-case-based-approach-educating-providers-policy-makers-and- … public-about-patient
The development of a case-based approach to educate patients and providers about … https://psnet.ahrq.gov/issue/faces-errors-case-based-approach-educating-providers-policy-makers-and-public-about-patient
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psnet.ahrq.gov/node/45325/psn-pdf
April 08, 2018 - Diagnosis is a team sport—partnering with allied health
professionals to reduce diagnostic errors: a case … Diagnosis is a team sport - partnering with allied health professionals to
reduce diagnostic errors: A case … psnet.ahrq.gov/issue/diagnosis-team-sport-partnering-allied-health-professionals-reduce-diagnostic-
errors-case … This case study describes five cases of dizziness, each incorrectly diagnosed by a physician and
subsequently … psnet.ahrq.gov/issue/diagnosis-team-sport-partnering-allied-health-professionals-reduce-diagnostic-errors-case
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
Case Objectives
Appreciate that … The Case
A 61-year-old man with a history of stroke initially presented to his primary care physician … In this case, a disconfirming clinician might ask "Is the other foot painful and numb?" … New England
Journal of Medicine when key words from the case were selected by an internist. … Teaching clinical reasoning: case-based and coached. Acad Med. 2010;85:1118-1124.
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psnet.ahrq.gov/node/46113/psn-pdf
July 12, 2017 - Optimizing a Business Case for Safe Health Care: An
Integrated Approach to Safety and Finance. … https://psnet.ahrq.gov/issue/optimizing-business-case-safe-health-care-integrated-approach-safety-and … This toolkit provides strategies for health care leaders to
develop a business case for patient safety … https://psnet.ahrq.gov/issue/optimizing-business-case-safe-health-care-integrated-approach-safety-and-finance … https://psnet.ahrq.gov/issue/optimizing-business-case-safe-health-care-integrated-approach-safety-and-finance
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psnet.ahrq.gov/node/34761/psn-pdf
November 15, 2016 - The Girl Who Died Twice: Every Patient's Nightmare: the
Libby Zion Case and the Hidden Hazards of Hospitals …
https://psnet.ahrq.gov/issue/girl-who-died-twice-every-patients-nightmare-libby-zion-case-and-hidden … The book is an interesting and
engaging account of a case and its aftermath, including the highly publicized … The book provides
an important historical context for this case and the debate surrounding it, the implications … https://psnet.ahrq.gov/issue/girl-who-died-twice-every-patients-nightmare-libby-zion-case-and-hidden-hazards-hospitals
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psnet.ahrq.gov/node/46357/psn-pdf
May 17, 2018 - Safe labeling practices to minimize medication errors in
anesthesia: 5 case reports and review of the … https://psnet.ahrq.gov/issue/safe-labeling-practices-minimize-medication-errors-anesthesia-5-case-reports … This commentary uses case examples
to illustrate how incorrect or incomplete labeling can affect care … https://psnet.ahrq.gov/issue/safe-labeling-practices-minimize-medication-errors-anesthesia-5-case-reports-and-review … https://psnet.ahrq.gov/issue/safe-labeling-practices-minimize-medication-errors-anesthesia-5-case-reports-and-review
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psnet.ahrq.gov/node/35909/psn-pdf
October 07, 2008 - Committed to Safety: Ten Case Studies on Reducing
Harm to Patients. … https://psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients
This report presents … ten case studies to illustrate interventions that address prominent and targeted areas
for patient … The authors also published an article about case studies in safety
improvement. … https://psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/36646/psn-pdf
April 19, 2011 - The business case for patient safety.
April 19, 2011
Hwang RW, Herndon JH. … The business case for patient safety. Clin Orthop Relat Res. 2007;457:21-34. … https://psnet.ahrq.gov/issue/business-case-patient-safety
The authors discuss the financial incentives … of improving patient outcomes as the business case for patient
safety. … https://psnet.ahrq.gov/issue/business-case-patient-safety
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psnet.ahrq.gov/node/44405/psn-pdf
September 02, 2015 - Ranking hospitals on avoidable death rates derived from
retrospective case record review: methodological … Ranking hospitals on avoidable death rates derived from retrospective case
record review: methodological … https://psnet.ahrq.gov/issue/ranking-hospitals-avoidable-death-rates-derived-retrospective-case-record … https://psnet.ahrq.gov/issue/ranking-hospitals-avoidable-death-rates-derived-retrospective-case-record-review … https://psnet.ahrq.gov/issue/ranking-hospitals-avoidable-death-rates-derived-retrospective-case-record-review
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psnet.ahrq.gov/node/45256/psn-pdf
July 01, 2017 - Applied use of safety event occurrence control charts of
harm and non-harm events: a case study. … Applied Use of Safety Event Occurrence Control Charts of Harm and
Non-Harm Events: A Case Study. … /psnet.ahrq.gov/issue/applied-use-safety-event-occurrence-control-charts-harm-and-non-harm-
events-case-study … Using a case study method, this commentary describes a tested incident assessment framework that
employs … ://psnet.ahrq.gov/issue/applied-use-safety-event-occurrence-control-charts-harm-and-non-harm-events-case-study
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psnet.ahrq.gov/node/34693/psn-pdf
February 10, 2011 - The authors obtained 21
standardized case abstracts in anesthesiology representing eight recognized … For each case, the authors prepared a matching case identical in every way, with the
exception that … if the true case resulted in mild reversible injury, the matching case was made to result in
severe … outcome was approximately 30% more likely to be
judged as substandard in comparison with the identical case
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psnet.ahrq.gov/node/35481/psn-pdf
December 30, 2012 - System errors in intrapartum electronic fetal monitoring:
a case review. … System errors in intrapartum electronic fetal monitoring: a case review. … https://psnet.ahrq.gov/issue/system-errors-intrapartum-electronic-fetal-monitoring-case-review
The author … presents a case analysis to illustrate common system errors in the use of intrapartum electronic
fetal … https://psnet.ahrq.gov/issue/system-errors-intrapartum-electronic-fetal-monitoring-case-review