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341. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37446/psn-pdf
     January 06, 2017 - The case of warfarin-related medication errors. … The case of warfarin-related medication errors. Jt Comm J Qual Patient Saf. 2008;34(1):36-45. … https://psnet.ahrq.gov/issue/how-useful-are-voluntary-medication-error-reports-case-warfarin-related- … https://psnet.ahrq.gov/issue/how-useful-are-voluntary-medication-error-reports-case-warfarin-related-medication-errors … https://psnet.ahrq.gov/issue/how-useful-are-voluntary-medication-error-reports-case-warfarin-related-medication-errors

342. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36020/psn-pdf
     June 21, 2006 - White blood cell left shift in a neonate: a case of mistaken identity. … https://psnet.ahrq.gov/issue/white-blood-cell-left-shift-neonate-case-mistaken-identity The authors … present a case study illustrating the value of taking a family medical history when caring for infants … https://psnet.ahrq.gov/issue/white-blood-cell-left-shift-neonate-case-mistaken-identity

343. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38653/psn-pdf
     May 20, 2009 - The frustrating case of incident-reporting systems. May 20, 2009 Shojania KG. … The frustrating case of incident-reporting systems. Qual Saf Health Care. 2008;17(6):400-2. … https://psnet.ahrq.gov/issue/frustrating-case-incident-reporting-systems This commentary discusses the … https://psnet.ahrq.gov/issue/frustrating-case-incident-reporting-systems

344. Another Fall | PSNet
     psnet.ahrq.gov/web-mm/another-fall
     June 01, 2010 - SPOTLIGHT CASE Another Fall Citation Text: Bogardus SG. Another Fall. … Two final thoughts occur to me as I review this case. … A case of death by physical restraint. New lessons from a photograph. … Sections Case Objectives Case & Commentary: Part 1 Case & Commentary: Part 2 … Case & Commentary: Part 3 Case & Commentary: Part 4 References Table Figures

345. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38199/psn-pdf
     March 03, 2011 - Patient safety indicators for England from hospital administrative data: case-control analysis and … Patient safety indicators for England from hospital administrative data: case-control analysis and comparison … https://psnet.ahrq.gov/issue/patient-safety-indicators-england-hospital-administrative-data-case-control … https://psnet.ahrq.gov/issue/patient-safety-indicators-england-hospital-administrative-data-case-control-analysis-and … https://psnet.ahrq.gov/issue/patient-safety-indicators-england-hospital-administrative-data-case-control-analysis-and

346. A Picture Speaks 1000 Words | PSNet
     psnet.ahrq.gov/web-mm/picture-speaks-1000-words
     July 16, 2015 - The Case A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A … The case was reviewed in light of the tragic outcome. … In this particular case, the overnight read by the resident was based on a comparison of the current … Following this case, data safety and monitoring policies were changed. … Unfortunately in this case, the workaround was inadequate.

347. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37096/psn-pdf
     June 24, 2010 - Impact of diagnosis-timing indicators on measures of safety, comorbidity, and case mix groupings from … Impact of diagnosis-timing indicators on measures of safety, comorbidity, and case mix groupings from … https://psnet.ahrq.gov/issue/impact-diagnosis-timing-indicators-measures-safety-comorbidity-and-case-mix … https://psnet.ahrq.gov/issue/impact-diagnosis-timing-indicators-measures-safety-comorbidity-and-case-mix-groupings … https://psnet.ahrq.gov/issue/impact-diagnosis-timing-indicators-measures-safety-comorbidity-and-case-mix-groupings

348. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36124/psn-pdf
     June 15, 2011 - System failure versus personal accountability--the case for clean hands. … System failure versus personal accountability--the case for clean hands. … https://psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands The author … https://psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands https://psnet.ahrq.gov

349. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35687/psn-pdf
     July 12, 2010 - Monitoring patient safety in health care: building the case for surrogate measures. … Monitoring patient safety in health care: building the case for surrogate measures. … https://psnet.ahrq.gov/issue/monitoring-patient-safety-health-care-building-case-surrogate-measures … https://psnet.ahrq.gov/issue/monitoring-patient-safety-health-care-building-case-surrogate-measures

350. The Missing Suction Tip | PSNet
     psnet.ahrq.gov/web-mm/missing-suction-tip
     January 01, 2006 - SPOTLIGHT CASE The Missing Suction Tip Citation Text: Thomas EJ, Moore FA. … Case Objectives Identify the risk factors for retained foreign bodies. … What went wrong in this case? … , along with provider fatigue (since it was an afternoon case). … Sections Case Objectives Case & Commentary: Part 1 Case & Commentary: Part 2

351. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45979/psn-pdf
     April 05, 2017 - Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine … Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine … psnet.ahrq.gov/issue/healthcare-system-wide-implementation-opioid-safety-guideline- recommendations-case-urine-drug … /psnet.ahrq.gov/issue/healthcare-system-wide-implementation-opioid-safety-guideline-recommendations-case-urine-drug … /psnet.ahrq.gov/issue/healthcare-system-wide-implementation-opioid-safety-guideline-recommendations-case-urine-drug

352. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36996/psn-pdf
     September 24, 2016 - Interruptions in a level one trauma center: a case study. … Interruptions in a level one trauma center: a case study. Int J Med Inform. 2008;77(4):235-41. … https://psnet.ahrq.gov/issue/interruptions-level-one-trauma-center-case-study The investigators shadowed … https://psnet.ahrq.gov/issue/interruptions-level-one-trauma-center-case-study

353. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35870/psn-pdf
     July 23, 2010 - Framing patient safety initiatives: working model and case example. … Framing patient safety initiatives: working model and case example. … https://psnet.ahrq.gov/issue/framing-patient-safety-initiatives-working-model-and-case-example The authors … https://psnet.ahrq.gov/issue/framing-patient-safety-initiatives-working-model-and-case-example

354. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37278/psn-pdf
     September 27, 2017 - The impact of team processes on psychiatric case management. September 27, 2017 Simpson A. … The impact of team processes on psychiatric case management. J Adv Nurs. 2007;60(4):409- 18. … https://psnet.ahrq.gov/issue/impact-team-processes-psychiatric-case-management This qualitative study … https://psnet.ahrq.gov/issue/impact-team-processes-psychiatric-case-management https://psnet.ahrq.gov

355. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40902/psn-pdf
     June 01, 2012 - The case for simulation as part of a comprehensive patient safety program. … The case for simulation as part of a comprehensive patient safety program. … https://psnet.ahrq.gov/issue/case-simulation-part-comprehensive-patient-safety-program Discussing the … https://psnet.ahrq.gov/issue/case-simulation-part-comprehensive-patient-safety-program https://psnet.ahrq.gov

356. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36692/psn-pdf
     January 18, 2011 - The objective medical emergency team activation criteria: a case-control study. … The objective medical emergency team activation criteria: a case- control study. … https://psnet.ahrq.gov/issue/objective-medical-emergency-team-activation-criteria-case-control-study … https://psnet.ahrq.gov/issue/objective-medical-emergency-team-activation-criteria-case-control-study

357. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36693/psn-pdf
     April 23, 2009 - From good intentions to successful implementation: the case of patient safety in Canada. … From good intentions to successful implementation: the case of patient safety in Canada. … https://psnet.ahrq.gov/issue/good-intentions-successful-implementation-case-patient-safety-canada The … https://psnet.ahrq.gov/issue/good-intentions-successful-implementation-case-patient-safety-canada

358. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37330/psn-pdf
     January 05, 2012 - Unreported errors in the intensive care unit: a case study of the way we work. … Unreported errors in the intensive care unit: a case study of the way we work. … https://psnet.ahrq.gov/issue/unreported-errors-intensive-care-unit-case-study-way-we-work This commentary … https://psnet.ahrq.gov/issue/unreported-errors-intensive-care-unit-case-study-way-we-work

359. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36974/psn-pdf
     February 05, 2014 - Measuring safety culture in healthcare: a case for accurate diagnosis. February 5, 2014 Flin R. … Measuring safety culture in healthcare: A case for accurate diagnosis. Saf Sci. 2007;45(6). … https://psnet.ahrq.gov/issue/measuring-safety-culture-healthcare-case-accurate-diagnosis The author … https://psnet.ahrq.gov/issue/measuring-safety-culture-healthcare-case-accurate-diagnosis https://psnet.ahrq.gov

360. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40212/psn-pdf
     April 04, 2011 - Creating effective quality-improvement collaboratives: a multiple case study. … Creating effective quality-improvement collaboratives: a multiple case study. … https://psnet.ahrq.gov/issue/creating-effective-quality-improvement-collaboratives-multiple-case-study … https://psnet.ahrq.gov/issue/creating-effective-quality-improvement-collaboratives-multiple-case-study