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psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - Preliminary chart review revealed multiple missed oncology appointments.
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - For example, studies show that the chart diagnosis of psychiatric inpatients frequently differs from
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - Over the six months following admission, the patient had 16 falls noted in her chart.
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - such as highlighting or placing a red exclamation point associated with the echocardiogram icon in the chart
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psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
October 02, 2024 - April 12, 2011
Targeted chart review of pediatric patient safety events identified by
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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
September 27, 2023 - A suicide assessment by the ED physician was not noted in chart; however, the nursing flowsheet contained
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - CNS vasculitis during the ensuing outpatient follow-up, in both the minds of the clinicians and the chart
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - Chart review or additional history-taking may have revealed the patient’s recent history of falls with
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - micronutrient dosing below or above accepted values.( 5,16 ) Despite a number of obvious advantages over paper charts
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psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
August 01, 2016 - severity scale for dental patient safety events, and developing tools to efficiently detect dental charts
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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk
Citation Text:
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quali…
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psnet.ahrq.gov/node/867359/psn-pdf
December 18, 2024 - Importance of Following Safe Practices for Infant Feeding
and Handling Expressed Breast Milk
December 18, 2024
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling
Expressed Breast Milk. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/importance-following-saf…
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - SPOTLIGHT CASE
Getting to the Root of the Matter
Citation Text:
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Schola…
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psnet.ahrq.gov/node/33858/psn-pdf
May 01, 2018 - The doctor and the patient have a
conversation, and then Alexa fills out the chart.
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
March 27, 2024 - And he creates a note in the chart that looks like a consult, an unbidden consult that the resident comes
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psnet.ahrq.gov/node/33866/psn-pdf
September 01, 2018 - OpenNotes puts more eyes on the chart.
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psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
August 31, 2020 - nurse needs to do a clear, concise assessment and have it documented so that when you're reading the chart
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psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
February 26, 2025 - OpenNotes puts more eyes on the chart.
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psnet.ahrq.gov/perspective/safety-across-board
August 31, 2020 - nurse needs to do a clear, concise assessment and have it documented so that when you're reading the chart