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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…
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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…
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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…
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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…
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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…
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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
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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
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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
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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…
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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…
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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.…
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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…
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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.…
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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…
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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…
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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
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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…
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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
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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:/…
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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