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1. Medicare's decision to withhold payment for hospital errors: the devil is in the details. | PSNet
   psnet.ahrq.gov/issue/medicares-decision-withhold-payment-hospital-errors-devil-details
   March 13, 2013 - Classic Medicare's decision to withhold payment for hospital errors: the devil is in the details … This commentary outlines the details of the proposed policy, the estimated impact on costs, and the expected

2. Psn-Pdf (pdf file)
   psnet.ahrq.gov/node/40255/psn-pdf
   March 02, 2011 - Medication details documented on hospital discharge: cross-sectional observational study of factors … Medication details documented on hospital discharge: cross- sectional observational study of factors … https://psnet.ahrq.gov/issue/medication-details-documented-hospital-discharge-cross-sectional- observational-study-factors … https://psnet.ahrq.gov/issue/medication-details-documented-hospital-discharge-cross-sectional-observational-study-factors … https://psnet.ahrq.gov/issue/medication-details-documented-hospital-discharge-cross-sectional-observational-study-factors

3. Psn-Pdf (pdf file)
   psnet.ahrq.gov/node/37499/psn-pdf
   January 10, 2017 - Medicare's decision to withhold payment for hospital errors: the devil is in the details. … https://psnet.ahrq.gov/issue/medicares-decision-withhold-payment-hospital-errors-devil-details Beginning … This commentary outlines the details of the proposed policy, the estimated impact on costs, and the … https://psnet.ahrq.gov/issue/medicares-decision-withhold-payment-hospital-errors-devil-details https:

4. Spotlight (pdf file)
   psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
   January 01, 2021 - healthcare providers can lead to retained packing after obstetric and surgical procedures 4 Case #1 Details … patient if “everything” had been removed; she said "yes" and was discharged to home 6 Case #1 Details … been removed – The patient said yes, that “it” had and was then discharged to home 9 Case #2 Details … Take-Home Points (3) 31 • Handoff information should include specific details about nature and amount … Case #1 Details Case #1 Details Case #2 Details Case #2 Details Case #2 Details Two cases of retained

5. Spotlight (pdf file)
   psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
   January 01, 2021 - All dates have been altered but reflect the actual duration between fill dates. 5 Case Details … Patient’s PDMP entries through SNF stay and subsequent outpatient visits Case Details (Encounter … Case Details Case Details (Encounter 1) Case Details (Encounter 1) Case Details (Encounter 2) … Case Details (Encounter 3) Case Details (Encounter 3) Case Details (Encounter 4) Case Details (Encounter … 4) Case Details (Encounter 5) Case Details (Encounter 6) Case Details (Encounter 6) Lost in transitions

6. Medication details documented on hospital discharge: cross-sectional observational study of factors associated with medication non-reconciliation. | PSNet
   psnet.ahrq.gov/issue/medication-details-documented-hospital-discharge-cross-sectional-observational-study-factors
   April 24, 2018 - Study Medication details documented on hospital discharge: cross-sectional observational … Medication details documented on hospital discharge: cross-sectional observational study of factors associated … Medication details documented on hospital discharge: cross-sectional observational study of factors associated

7. Spotlight (pdf file)
   psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
   January 01, 2022 - strategies for optimal management of patients administered perioperative opioid therapy 4 Case #1 Details … • Upon admission, home doses of an antidepressant and lorazepam were continued. 5 Case #1 Details … respiratory deficit, he was successfully weaned off mechanical ventilation and extubated. 6 Case #2 Details … was stabilized medically and sent to surgery for a trans-metatarsal foot amputation. 7 Case #2 Details … (1) Case #1 Details (2) Case #2 Details (1) Case #2 Details (2) Case #2 Details (3) Patient Safety

8. Spotlight (pdf file)
   psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
   January 01, 2022 - complications associated with bronchoscopy and strategies to improve perioperative safety 4 Case Details … The patient recovered without change in respiratory symptoms or vital signs in the PACU. 5 Case Details … to follow up “as needed,” as his vital signs and respiratory symptoms remained normal. 6 Case Details … day after treatment with supplemental oxygen; thoracostomy drainage was not necessary. 7 Case Details … (1) Case Details (2) Case Details (3) Case Details (4) False Assumptions Result in a Missed Pneumothorax

9. Psn-Pdf (pdf file)
   psnet.ahrq.gov/node/37144/psn-pdf
   May 16, 2008 - health-care-associated-infections https://psnet.ahrq.gov/issue/medicares-decision-withhold-payment-hospital-errors-devil-details … https://psnet.ahrq.gov/issue/medicares-decision-withhold-payment-hospital-errors-devil-details

10. The role of housestaff in implementing medication reconciliation on admission at an academic medical center. | PSNet
    psnet.ahrq.gov/issue/role-housestaff-implementing-medication-reconciliation-admission-academic-medical-center
    March 30, 2011 - This article details how one academic medical center engaged housestaff in tactics  to achieve higher … March 30, 2011 Medication details documented on hospital discharge: cross-sectional observational

11. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
    January 01, 2020 - crowding, limitations of the ED triage process, and failures of teamwork and communication. 4 Case Details … Respiratory rate 16 breaths/minute – Pulse oximetry 98% on room air – Oral temperature 36.6˚C 5 Case Details … resuscitation room and assessed by the Emergency Medicine attending physician and resident 6 Case Details … Vascular Surgery evaluated patient and agreed to take the patient to the operating room (OR) 7 Case Details … Case Details Case Details Case Details �SOME PATIENTS CAN’T WAIT: IMPROVING TIMELINESS OF EMERGENCY

12. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
    January 01, 2021 - radiologists and referring physicians can contribute to delays in diagnosis and treatment 4 Case Details … most possibly artifact, however follow-up chest X-ray is advised for further evaluation” 5 Case Details … any knowledge of or follow-up for the “soft tissue density” in the left suprahilar region 6 Case Details … Source and Credits Objectives The Consequences of miscommunication regarding a possible artifact Case Details … Case Details Case Details The consequences of miscommunication regarding a possible artifact Communication

13. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
    January 01, 2022 - psychosocial history contributed to poor care for an older man with metastatic prostate cancer 4 Case Details … Urinalysis revealed large leukocyte esterase and many white blood cells. 5 Case Details (2) • The … • The palliative care service was consulted to clarify goals of care. 6 Case Details (3) • Further … • However, he continued to miss scheduled appointments. 7 Case Details (4) • He presented to clinic … (1) Case Details (2) Case Details (3) Case Details (4) Case Details (5) A Case of Mistaken Capacity

14. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43393/psn-pdf
    July 30, 2014 - safe-surgery-saves-lives-second-global-patient-safety-challenge https://psnet.ahrq.gov/issue/medicares-decision-withhold-payment-hospital-errors-devil-details … https://psnet.ahrq.gov/issue/medicares-decision-withhold-payment-hospital-errors-devil-details https

15. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38533/psn-pdf
    January 31, 2011 - measuring-preventable-harm-helping-science-keep-pace-policy https://psnet.ahrq.gov/issue/medicares-decision-withhold-payment-hospital-errors-devil-details … https://psnet.ahrq.gov/issue/medicares-decision-withhold-payment-hospital-errors-devil-details https

16. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
    January 01, 2022 - infection and strategies to improve identification of patients at risk of this infection 5 Case Details … the US in the 1980s, travels frequently to Haiti, the Dominican Republic, Central America 6 Case Details … • He was admitted to the intensive care unit. 7 Case Details • He was treated with fluids, pressors … Acknowledgements Objectives Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis  Case Details … Case Details Case Details Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis

17. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
    January 01, 2022 - how to prevent diagnostic errors that can impede early identification and treatment. 4 Case Details … scattered petechial hemorrhages and mucosal thickening on both the EGD and colonoscopy.) 5 Case Details … No imaging was performed. 6 Case Details (3) • Finally, another gastroenterologist covering for … Spotlight Source and Credits Objectives Delayed Diagnosis of Mesenteric Ischemia  Case Details (1 … ) Case Details (2) Case Details (3) Case Details (4) Delayed Diagnosis of Mesenteric Ischemia  Background

18. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
    January 01, 2022 - patient history and abdominal anatomy when considering approaches to abdominal entry 4 Case Details … oophorectomy was a mixed echogenic ovarian mass concerning for possible ovarian cancer. 5 Case Details … another hospital 9 hours after being discharged, due to increasing pain, nausea, and fever. 6 Case Details … fascia was closed, the skin was left open, and a negative pressure dressing was applied. 7 Case Details … (1) Case Details (2) Case Details (3) Case Details (4) Fecal Contamination of the Peritoneum from

19. Preventing accidents and injuries in the MRI suite. | PSNet
    psnet.ahrq.gov/issue/preventing-accidents-and-injuries-mri-suite
    July 18, 2024 - Please refer to the information link below for further details.

20. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
    January 01, 2023 - communication, and a culture of safety can improve care in complex health care situations. 4 Case Details … • Maternal Fetal Medicine (MFM), endocrinology, and gastroenterology were consulted. 5 Case Details … developed a progressively worsening metabolic acidosis with an anion gap peaking at 20. 6 Case Details … Objectives Slide 4: Prolonged DKA in Pregnancy: A Case of Communication Breakdown Slide 5: Case Details … (1) Slide 6: Case Details (2) Slide 7: Case Details (3) Slide 8: Prolonged DKA in Pregnancy: A Case