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psnet.ahrq.gov/issue/electronic-health-record-based-real-time-analytics-program-patient-safety-surveillance-and
May 19, 2018 - Study
An electronic health record–based real-time analytics program for patient safety surveillance and improvement.
Citation Text:
Classen D, Li M, Miller S, et al. An Electronic Health Record-Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement. Health Aff …
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psnet.ahrq.gov/issue/national-survey-assessing-number-records-allowed-open-electronic-health-records-hospitals-and
May 29, 2019 - Study
A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites.
Citation Text:
Adelman JS, Berger MA, Rai A, et al. A national survey assessing the number of records allowed open in electronic health records at hospital…
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psnet.ahrq.gov/innovation/implementation-medication-reconciliation-risk-stratification-tool-integrated-within
April 12, 2023 - EMERGING INNOVATIONS
Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.
Citation Text:
Chu ES, El-Kareh R, Biondo A, et al. Implementation of a medication reconciliation risk stratif…
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psnet.ahrq.gov/issue/cost-quality-academic-health-centers-annual-costs-its-quality-and-patient-safety
October 14, 2020 - Study
The cost of quality: an academic health center's annual costs for its quality and patient safety infrastructure.
Citation Text:
Blanchfield BB, Demehin AA, Cummings CT, et al. The cost of quality: an academic health center's annual costs for its quality and patient safety infrastru…
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psnet.ahrq.gov/issue/good-care-slow-enough-be-able-pay-attention-primary-care-time-scarcity-and-patient-safety
August 04, 2015 - Study
"Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety.
Citation Text:
Satterwhite S, Nguyen M-LT, Honcharov V, et al. "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. J Gen Intern …
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psnet.ahrq.gov/issue/sustained-user-engagement-health-information-technology-long-road-implementation-system
December 21, 2022 - Study
Sustained user engagement in health information technology: the long road from implementation to system optimization of computerized physician order entry and clinical decision support systems for prescribing in hospitals in England.
Citation Text:
Cresswell K, Lee L, Mozaffar H, e…
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psnet.ahrq.gov/issue/weekend-effect-hospital-mortality-ischemic-and-hemorrhagic-stroke-us-rural-and-urban
January 19, 2022 - Study
Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals.
Citation Text:
Mekonnen B, Wang G, Rajbhandari-Thapa J, et al. Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals. J…
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - 40 of K
November 1, 2003
Lesar TS. 40 of K. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/40-k
The Case
An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve
replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
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psnet.ahrq.gov/node/49518/psn-pdf
August 01, 2006 - It's All in the Syringe
August 1, 2006
Weingart SN. It's All in the Syringe. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/its-all-syringe
The Case
A 33-year-old man with type 2 diabetes presented to his physician's office to discuss his diabetes
management. The patient admitted not taking his medications…
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psnet.ahrq.gov/node/49444/psn-pdf
May 01, 2004 - Do Me a Favor
May 1, 2004
Williamson A. Do Me a Favor. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/do-me-favor
The Case
A 26-year-old gravida 4 para 1 woman reported that her last menstrual period was 5 weeks prior, and she
had a positive home pregnancy test. With a history of one ectopic pregnancy, one…
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psnet.ahrq.gov/node/49476/psn-pdf
March 02, 2005 - Around the Block
March 1, 2005
Minichiello T. Around the Block. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/around-block
The Case
A 77-year-old woman with multiple medical problems was admitted to the hospital for an elective knee
replacement. The orthopedic surgeon, recognizing the risk of deep vein th…
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psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx
Spotlight
Premature Closure: Was it Just Syncope?
Source and Credits
• This presentation is based on the November 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit i…
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psnet.ahrq.gov/node/49731/psn-pdf
April 01, 2015 - Fire in the Hole!—An OR Fire
April 1, 2015
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fire-hole-or-fire
The Case
A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection
for a biopsy-proven adenocarcinom…
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psnet.ahrq.gov/node/49523/psn-pdf
November 01, 2006 - Urinary Retention Dilemma
November 1, 2006
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma
The Case
Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy
(BPH) and urinary hesitancy returned to th…
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psnet.ahrq.gov/node/49694/psn-pdf
October 01, 2013 - Are You Mrs. A? An Issue of Identification Over
Telephone
October 1, 2013
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
The Case
Mr. A was a 78-year-old man admitted with non-ST elevation…
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psnet.ahrq.gov/node/49835/psn-pdf
January 01, 2020 - Don't Pick the PICC
July 1, 2018
McGill RL. Don't Pick the PICC. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/dont-pick-picc
The Case
A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy;
glaucoma; and stage IV chronic kidney disease was admitted to the hospita…
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Danger in Disruption
October 1, 2009
Fontaine DK. Danger in Disruption. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/danger-disruption
The Case
A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had
metabolic alkalosis (pH = 7.58), and her last peripheral…
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psnet.ahrq.gov/node/73335/psn-pdf
May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition
Error
May 26, 2021
Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
The Case
A 4-year-old (former 33-week premature) boy with a …
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psnet.ahrq.gov/node/49517/psn-pdf
August 01, 2006 - Miscalculated Risk
August 1, 2006
Strassels SA. Miscalculated Risk. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/miscalculated-risk
The Case
A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after lifting his 2-
week-old infant. He received Vicodin (hydrocodone and a…
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psnet.ahrq.gov/node/33884/psn-pdf
July 01, 2019 - Emerging Safety Issues in Artificial Intelligence
July 1, 2019
Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
Perspective
Background
Since the beginning of digital health records, there has bee…