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361. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49692/psn-pdf
     September 01, 2013 - https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words The Case A 62-year-old man with a past medical … 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.

362. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41764/psn-pdf
     January 18, 2013 - the impact of the AHRQ Patient Safety Indicators (PSIs) on the Veterans Health Administration: the case … the impact of the AHRQ Patient Safety Indicators (PSIs) on the Veterans Health Administration: the case … psnet.ahrq.gov/issue/examining-impact-ahrq-patient-safety-indicators-psis-veterans-health- administration-case … psnet.ahrq.gov/issue/examining-impact-ahrq-patient-safety-indicators-psis-veterans-health-administration-case … psnet.ahrq.gov/issue/examining-impact-ahrq-patient-safety-indicators-psis-veterans-health-administration-case

363. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42311/psn-pdf
     May 29, 2013 - We know what they did wrong, but not why: the case for 'frame-based' feedback. … We knowwhatthey did wrong, but notwhy: the case for ‘frame-based’ feedback. … https://psnet.ahrq.gov/issue/we-know-what-they-did-wrong-not-why-case-frame-based-feedback This commentary … https://psnet.ahrq.gov/issue/we-know-what-they-did-wrong-not-why-case-frame-based-feedback https://psnet.ahrq.gov

364. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39262/psn-pdf
     March 04, 2011 - Unintended errors with EHR-based result management: a case series. … Unintended errors with EHR-based result management: a case series. … https://psnet.ahrq.gov/issue/unintended-errors-ehr-based-result-management-case-series The authors identify … https://psnet.ahrq.gov/issue/unintended-errors-ehr-based-result-management-case-series https://psnet.ahrq.gov

365. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35985/psn-pdf
     January 02, 2017 - Coalition: making the case for full disclosure. January 2, 2017 Wojcieszak D, Banja J, Houk C. … Coalition: Making the Case for Full Disclosure. … https://psnet.ahrq.gov/issue/sorry-works-coalition-making-case-full-disclosure The authors describe … https://psnet.ahrq.gov/issue/sorry-works-coalition-making-case-full-disclosure https://psnet.ahrq.gov

366. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35774/psn-pdf
     July 20, 2010 - Rules, safety and the narrativisation of identity: a hospital operating theatre case study. … Rules, safety and the narrativisation of identity: a hospital operating theatre case study. … https://psnet.ahrq.gov/issue/rules-safety-and-narrativisation-identity-hospital-operating-theatre-case-study … https://psnet.ahrq.gov/issue/rules-safety-and-narrativisation-identity-hospital-operating-theatre-case-study

367. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35612/psn-pdf
     June 23, 2010 - Case-control analysis of the financial cost of medication errors in hospitalized patients. … Case-control analysis of the financial cost of medication errors in hospitalized patients. … https://psnet.ahrq.gov/issue/case-control-analysis-financial-cost-medication-errors-hospitalized-patients … https://psnet.ahrq.gov/issue/case-control-analysis-financial-cost-medication-errors-hospitalized-patients

368. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39595/psn-pdf
     June 15, 2011 - Application of human error theory in case analysis of wrong procedures. June 15, 2011 Duthie EA. … Application of Human Error Theory in Case Analysis of Wrong Procedures. … https://psnet.ahrq.gov/issue/application-human-error-theory-case-analysis-wrong-procedures This study … https://psnet.ahrq.gov/issue/application-human-error-theory-case-analysis-wrong-procedures https://psnet.ahrq.gov

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40164/psn-pdf
     February 15, 2011 - Patient risk factors for medical injury: a case–control study. … Patient risk factors for medical injury: a case-control study. … https://psnet.ahrq.gov/issue/patient-risk-factors-medical-injury-case-control-study This study observed … https://psnet.ahrq.gov/issue/patient-risk-factors-medical-injury-case-control-study https://psnet.ahrq.gov

370. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37359/psn-pdf
     January 02, 2017 - Case study: preventing surgical complications at Baystate Medical Center. … Case Study: Preventing Surgical Complications at Baystate Medical Center. … https://psnet.ahrq.gov/issue/case-study-preventing-surgical-complications-baystate-medical-center This … https://psnet.ahrq.gov/issue/case-study-preventing-surgical-complications-baystate-medical-center

371. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37652/psn-pdf
     September 24, 2010 - Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System. … Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System. … https://psnet.ahrq.gov/issue/case-study-getting-boards-board-allen-memorial-hospital-iowa-health-system … https://psnet.ahrq.gov/issue/case-study-getting-boards-board-allen-memorial-hospital-iowa-health-system

372. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42291/psn-pdf
     September 12, 2016 - Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. … Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. … https://psnet.ahrq.gov/issue/human-cognition-and-dynamics-failure-rescue-lewis-blackman-case This commentary … https://psnet.ahrq.gov/issue/human-cognition-and-dynamics-failure-rescue-lewis-blackman-case https://

373. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36965/psn-pdf
     February 15, 2011 - Strategic work-arounds to accommodate new technology: the case of smart pumps in hospital care. … https://psnet.ahrq.gov/issue/strategic-work-arounds-accommodate-new-technology-case-smart-pumps- hospital-care … https://psnet.ahrq.gov/issue/strategic-work-arounds-accommodate-new-technology-case-smart-pumps-hospital-care … https://psnet.ahrq.gov/issue/strategic-work-arounds-accommodate-new-technology-case-smart-pumps-hospital-care

374. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41568/psn-pdf
     April 05, 2013 - Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review … Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review … //psnet.ahrq.gov/issue/preventable-deaths-due-problems-care-english-acute-hospitals-retrospective- case-record-review … https://psnet.ahrq.gov/issue/preventable-deaths-due-problems-care-english-acute-hospitals-retrospective-case-record-review … https://psnet.ahrq.gov/issue/preventable-deaths-due-problems-care-english-acute-hospitals-retrospective-case-record-review

375. Standard Deviations | PSNet
     psnet.ahrq.gov/web-mm/standard-deviations
     January 01, 2006 - SPOTLIGHT CASE Standard Deviations Citation Text: Sabin JE. … "( 3 ) In this case, the hospital team provided excellent diagnosis and treatment planning. … It is common for clinicians to see a patient like the man in this case as an extreme "other." … Understanding service disengagement from the perspective of case managers. … Sections Case Objectives Case & Commentary: Part 1 Case & Commentary: Part 2

376. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39730/psn-pdf
     December 21, 2014 - Surgical case listing accuracy: failure analysis at a high- volume academic medical center. … Surgical case listing accuracy: failure analysis at a high-volume academic medical center. … https://psnet.ahrq.gov/issue/surgical-case-listing-accuracy-failure-analysis-high-volume-academic-medical … https://psnet.ahrq.gov/issue/surgical-case-listing-accuracy-failure-analysis-high-volume-academic-medical-center … https://psnet.ahrq.gov/issue/surgical-case-listing-accuracy-failure-analysis-high-volume-academic-medical-center

377. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37847/psn-pdf
     June 18, 2008 - Effect of the 80-hour work week on resident case coverage. … Effect of the 80-hour work week on resident case coverage. … https://psnet.ahrq.gov/issue/effect-80-hour-work-week-resident-case-coverage Implementation of duty … https://psnet.ahrq.gov/issue/effect-80-hour-work-week-resident-case-coverage https://psnet.ahrq.gov/issue

378. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38576/psn-pdf
     April 22, 2009 - A case of mistaken identity: staff input on patient ID errors. … A case of mistaken identity: staff input on patient ID errors. … https://psnet.ahrq.gov/issue/case-mistaken-identity-staff-input-patient-id-errors Preventing the wrong … https://psnet.ahrq.gov/issue/case-mistaken-identity-staff-input-patient-id-errors https://psnet.ahrq.gov

379. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39844/psn-pdf
     November 02, 2010 - Safety through redundancy: a case study of in-hospital patient transfers. … Safety through redundancy: a case study of in-hospital patient transfers. … https://psnet.ahrq.gov/issue/safety-through-redundancy-case-study-hospital-patient-transfers This study … https://psnet.ahrq.gov/issue/safety-through-redundancy-case-study-hospital-patient-transfers https://

380. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45834/psn-pdf
     February 22, 2017 - Implementing an error disclosure coaching model: a multicenter case study. … Implementing an error disclosure coaching model: A multicenter case study. … https://psnet.ahrq.gov/issue/implementing-error-disclosure-coaching-model-multicenter-case-study This … https://psnet.ahrq.gov/issue/implementing-error-disclosure-coaching-model-multicenter-case-study https