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81. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73866/psn-pdf
    September 22, 2021 - Role of nursing home quality on COVID-19 cases and deaths: evidence from Florida nursing homes. … Role of nursing home quality on COVID-19 cases and deaths: evidence from Florida nursing homes. … https://psnet.ahrq.gov/issue/role-nursing-home-quality-covid-19-cases-and-deaths-evidence-florida- nursing-homes … in Florida, this study explored the association between nursing home characteristics and COVID-19 cases … Findings suggest that the likelihood of COVID-19 cases in nursing homes is related to ownership status

82. Challenges of Diabetes Management and Medication Reconciliation | PSNet
    psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
    March 15, 2023 - When a root-cause-analysis approach is applied to the cases cited above, errors in obtaining accurate … May 16, 2022 WebM&M Cases Wrong Catheter in the … October 1, 2009 WebM&M Cases Blind Spot June … 1, 2005 WebM&M Cases Not a Miscarriage June … September 8, 2021 WebM&M Cases When Looks Aren’t All

83. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/74079/psn-pdf
    December 02, 2020 - Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases: a pragmatic … Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases: a pragmatic … psnet.ahrq.gov/issue/impact-digitally-acquired-peer-diagnostic-input-diagnostic-confidence- outpatient-cases … In cases with high diagnostic uncertainly, peer input increased provider confidence. … psnet.ahrq.gov/issue/impact-digitally-acquired-peer-diagnostic-input-diagnostic-confidence-outpatient-cases

84. Final Progress Report: The Role of Collective Mindfulness in Delivering Reliable and Safe Perioperative Care to Neonates (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/france-report.pdf
    January 01, 2024 - Slagle used AV-recorded cases from our NICHD R01 archive of actual cases to build example sets for each … significantly interrupted our accrual of recorded cases … of the 23 total AV cases had corresponding clinician-reported SOS data. … These 18 cases were used to complete the preliminary concordance analysis. … Summary of Aim 3 findings Eighteen cases of the 23 total A-V cases had corresponding clinician-reported

85. Framing of clinical information affects physicians' diagnostic accuracy. | PSNet
    psnet.ahrq.gov/issue/framing-clinical-information-affects-physicians-diagnostic-accuracy
    November 02, 2011 - Using hypothetical patient cases, researchers found that the way in which cases were presented had a … Improving Diagnostic Safety and Quality April 26, 2023 WebM&M Cases … October 10, 2018 WebM&M Cases Tough Call: Addressing … April 4, 2011 WebM&M Cases Defensive Medicine: "Glowing … July 10, 2008 WebM&M Cases The Dropped Lung May 1

86. UChicago Medicine Reduces Perioperative Venous Thromboembolism with AHRQ's Toolkit | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/about/uni-chicago-medicine.html
    February 01, 2024 - institution for all flagged PSI #12 (Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate) cases … Nursing units and surgical services with the largest volume of PSI #12 cases were selected to implement … While there was a 30% reduction in PSI #12 cases across the institution when comparing calendar year … evidence-best practices for VTE prevention and a gap analysis across our institution for all flagged PSI #12 cases … 08/18/22–10/20/22 Nursing units and surgical services with the largest volume of PSI #12 cases

87. Final Progress Report: MammoTutor: An Internet-Based Computer Tutoring System to Teach General Radiologists the Early Signs of Breast Cancer (pdf file)
    www.ahrq.gov/sites/default/files/2025-05/mello-thoms-report.pdf
    January 01, 2025 - However, due to lack of sufficient cases of cancers more predominant amongst African American women … Conclusion: Although full system implementation has not been tested, accrual of cases continues as … Based on our estimate of possible improvement, we determined that a minimum of 418 mammogram cases … We decided to use approximately 450 cases for training and also include 50 cases for pre- and post- … , but the database is lacking more cases representing African American women.

88. CHIPRA 201: Section 7, Tables 4-7 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-201-asthma-section-7-table-4-7.pdf
    June 02, 2025 - (8.3) * Data summarize characteristics of the broader population residing in ZIP codes of sampled cases … 18.4) * Data summarize characteristics of the broader population residing in ZIP codes of sampled cases … $200,724 * Data summarize characteristics of the broader population residing in ZIP codes of sampled cases … 100 * Data summarize characteristics of the broader population residing in ZIP codes of sampled cases

89. Calibrate Dx: A Resource to Improve Diagnostic Decisions - Appendix A (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/multiple/Calibrate-Dx-AppendixA.pdf
    June 02, 2025 - Reflections and Assessment WRITE A SUMMARY ASSESSMENT AFTER REVIEWING YOUR CASES. … What will you repeat in similar cases in the future? … • What will you do differently in similar cases in the future? … Task Formulating Questions to Guide Calibration Evaluate Diagnostic Performance Learn from your own cases

90. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60793/psn-pdf
    August 12, 2020 - Is there a link between nursing home reported quality and COVID-19 cases? … Is There a link between nursing home reported quality and COVID-19 cases? … https://psnet.ahrq.gov/issue/there-link-between-nursing-home-reported-quality-and-covid-19-cases- evidence-california … with state-level data to examine the association between nursing home-reported quality and COVID-19 cases … residents, results indicate that nursing homes with higher ratings were less likely to experience COVID-19 cases

91. Executive Summary | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/summary.html
    August 01, 2022 - offered compensation in 3 of these 11 cases. … acknowledging responsibility) made in 64% of cases. … Of the 32 cases, 15 were settled and 17 were voluntarily dismissed. … Across these cases, the median time between filing and disposition of the case was 189 days. … While 326 cases had descriptive data available, 716 cases entered JDN and 165 reached a final disposition

92. Hospital Expands Use of AHRQ’s QI Toolkit To Improve Patient Safety Measures Prioritized by Medicare (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/standalone_psi_casestudy.pdf
    June 02, 2025 - To identify cases of preventable harm to patients. 2. … To develop a standardized method for tracking and referring such preventable cases in need of review … • Carefully track what you learn when you review individual cases. … Cases of accidental puncture, for example, were attributed to multiple surgical teams. … per thousand or cases per catheter day.

93. Final Progress Report: Building the Evidence Base for Vomit Clean-Up Procedures in Long-Term Care Facilities (pdf file)
    www.ahrq.gov/sites/default/files/2024-05/fraser-report.pdf
    January 01, 2024 - Cases who vomited infected 2.74 (95% CI: 1.90, 3.94) more individuals than did nonvomiters; cases with … diarrhea infected 1.62 (95% CI: 1.09, 2.41) more individuals than did cases without diarrhea; and resident-cases … cases compared with nonindex cases. … if those cases are residents. … cases compared with cases without vomiting, and LTCF residents infected 1.31 (95% CI: 1.15, 1.50) times

94. Comparative accuracy of diagnosis by collective intelligence of multiple physicians vs individual physicians. | PSNet
    psnet.ahrq.gov/issue/comparative-accuracy-diagnosis-collective-intelligence-multiple-physicians-vs-individual
    January 23, 2017 - Physicians can enter cases onto the platform or solve cases that others have entered. … physicians across specialties outperformed individual subspecialists even for subspecialty-relevant cases … Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases … March 27, 2019 Teaching about diagnostic errors through virtual patient cases: a pilot … Exposure to media information about a disease can cause doctors to misdiagnose similar-looking clinical cases

95. Extent of diagnostic agreement among medical referrals. | PSNet
    psnet.ahrq.gov/issue/extent-diagnostic-agreement-among-medical-referrals
    October 31, 2011 - This retrospective medical record review study examined cases where primary care providers sought diagnostic … They found that the diagnosis differed substantially in about one-fifth of cases following the subspecialty … Costs were higher for cases with substantively different diagnoses compared to cases where subspecialists … December 5, 2018 WebM&M Cases Transfusion Thresholds … October 8, 2008 WebM&M Cases Inappropriate Antibiotic

96. Right Electrocardiogram, Wrong Patient | PSNet
    psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
    April 24, 2024 - The Cases Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary … All of the cases involved the nurse or EKG technician either entering the wrong medical record number … Fortunately, there were no adverse effects on any of the patients involved in the cases of mentioned … Systems Changes Needed and Quality Improvement Approach In reviewing the cases, the team sought to … In the majority of the cases, the error was detected by the nurse or clerk prior to EKG transmission

97. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867683/psn-pdf
    March 05, 2025 - Ambulatory medication errors and adverse events involved in medicine-related malpractice cases from … Ambulatory medication errors and adverse events involved in medicine- related malpractice cases from … psnet.ahrq.gov/issue/ambulatory-medication-errors-and-adverse-events-involved-medicine-related- malpractice-cases … psnet.ahrq.gov/issue/ambulatory-medication-errors-and-adverse-events-involved-medicine-related-malpractice-cases … psnet.ahrq.gov/issue/ambulatory-medication-errors-and-adverse-events-involved-medicine-related-malpractice-cases

98. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47644/psn-pdf
    February 13, 2019 - Using computerized virtual cases to explore diagnostic error in practicing physicians. … Using computerized virtual cases to explore diagnostic error in practicing physicians. … https://psnet.ahrq.gov/issue/using-computerized-virtual-cases-explore-diagnostic-error-practicing- physicians … This simulation study presented virtual patient cases to practicing physicians with the aim of improving … https://psnet.ahrq.gov/issue/using-computerized-virtual-cases-explore-diagnostic-error-practicing-physicians

99. Disclosing harmful medical errors to patients: tackling three tough cases. | PSNet
    psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-tackling-three-tough-cases
    December 19, 2018 - Commentary Disclosing harmful medical errors to patients: tackling three tough cases … Disclosing harmful medical errors to patients: tackling three tough cases. … Disclosing harmful medical errors to patients: tackling three tough cases.

100. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866731/psn-pdf
     September 18, 2024 - Root cause analysis of cases involving diagnosis. … Root cause analysis of cases involving diagnosis. … https://psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis Root cause analysis (RCA) … While the five overarching steps of RCA for cases involving diagnostic error are similar to standard … https://psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis https://psnet.ahrq.gov/primer