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  1. psnet.ahrq.gov/issue/potentially-inappropriate-medications-defined-stopp-criteria-and-risk-adverse-drug-events
    April 22, 2015 - Study Classic Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Citation Text: Hamilton H, Gallagher P, Ryan C, et al. Potentially inappropriate medications defined by STOPP crit…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49602/psn-pdf
    April 01, 2010 - Anticoagulation: Held Too Long April 1, 2010 Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/anticoagulation-held-too-long The Case A 68-year-old woman with a history of mitral valve replacement with a mechanical valve was admitted with abdominal pain. Because of the…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36907/psn-pdf
    September 14, 2012 - Serious Reportable Events in Healthcare—2011 Update. September 14, 2012 Washington DC: National Quality Forum; December 2011. https://psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update The National Quality Forum originally defined 27 health care "never events"—patient safety events that pose ser…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40692/psn-pdf
    October 04, 2011 - Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice. October 4, 2011 Booth CMA, Moore CE, Eddleston J, et al. Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866265/psn-pdf
    July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport July 31, 2024 MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840174/psn-pdf
    August 28, 2024 - related to an offer of compensation would not be applicable to this case but would be important when considering
  7. psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
    January 01, 2021 - level, physicians should be aware of, and take action to address, their cognitive biases such as considering
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850362/psn-pdf
    June 14, 2023 - of medications that are effective for treating the conditions commonly seen at that facility while considering
  9. psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
    September 25, 2024 - SPOTLIGHT CASE CME/MOC New Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations Citation Text: Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNe…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39404/psn-pdf
    March 31, 2010 - Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. March 31, 2010 Cohen SP, Hayek SM, Datta S, et al. Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. Anesthesiology. 2010;112(3):711-8. doi:10.1097/ALN.0b013e3181cf892d. h…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45231/psn-pdf
    February 14, 2017 - 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. February 14, 2017 Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. BMJ. 2016;352:h6781. doi:10.1136/bmj.h6781. https://psnet.…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37417/psn-pdf
    March 28, 2012 - Medication use leading to emergency department visits for adverse drug events in older adults. March 28, 2012 Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147(11):755-765. https://psnet.ahrq.gov/issue/med…
  13. 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 study. April 5, 2013 Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf. 2012;21(9):737-745. doi:10.…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42067/psn-pdf
    March 18, 2013 - Methodological variations and their effects on reported medication administration error rates. March 18, 2013 McLeod MC, Barber N, Franklin BD. Methodological variations and their effects on reported medication administration error rates. BMJ Qual Saf. 2013;22(4):278-89. doi:10.1136/bmjqs-2012-001330. https://psne…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37940/psn-pdf
    June 16, 2010 - Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not? June 16, 2010 Weissman JS, Schneider EC, Weingart SN, et al. Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do n…
  16. psnet.ahrq.gov/web-mm/compare-and-contrast
    July 16, 2019 - The clinician considering the use of a contrast study in an at-risk patient must consider first the possibility
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42639/psn-pdf
    November 08, 2013 - An intervention model that promotes accountability: peer messengers and patient/family complaints. November 8, 2013 Pichert JW, Moore IN, Karrass J, et al. An intervention model that promotes accountability: peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf. 2013;39(10):435-446. https://psn…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74242/psn-pdf
    January 07, 2022 - Considering the case presented, direct verification from the patient that they presented for the expected
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73901/psn-pdf
    September 29, 2021 - Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors September 29, 2021 Searns JB, Williams MC, MacBrayne CE, et al. Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. Diagnosis (Berl). 2020;8(3):347-352. doi:10.1515/dx-2020-0032. https:/…
  20. psnet.ahrq.gov/web-mm/transfer-or-not-transfer
    November 23, 2016 - In considering this question, the first issue is determining whether the patient would have been classified

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