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psnet.ahrq.gov/node/39672/psn-pdf
December 17, 2010 - prevalence-and-predictors-adverse-events-older-surgical-patients-impact-present-admission
https://psnet.ahrq.gov/issue/medicares-decision-withhold-payment-hospital-errors-devil-details
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psnet.ahrq.gov/issue/how-can-health-care-organizations-become-more-health-literate-workshop-summary
October 08, 2014 - This report details the results of a workshop on health literacy in health care organizations.
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psnet.ahrq.gov/issue/acting-concerns-your-professional-responsibility
April 02, 2014 - This report details how clinicians can speak up and discuss concerns that may affect safety in surgical
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psnet.ahrq.gov/issue/lessons-americas-safest-hospitals
November 16, 2016 - This magazine article details how several hospitals have taken a comprehensive approach to improving
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psnet.ahrq.gov/issue/doctors-use-more-devices-potential-distraction-grows
March 06, 2005 - widespread use of mobile devices (such as iPads and smartphones) in health care, this newspaper article details
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psnet.ahrq.gov/issue/computerized-medication-order-errors-studied
March 26, 2014 - This news article details how research on errors related to computerized provider order entry may help
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psnet.ahrq.gov/issue/medical-mistakes-no-longer-billable-bold-steps-taken-state-reduce-hospital-errors
August 06, 2008 - not reimburse hospitals for care related to 28 preventable errors , though they have not specified details
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psnet.ahrq.gov/issue/nurse-physician-communications-connecting-safety
July 29, 2009 - Exploring communication gaps and errors between nurses and physicians , this article details how safety
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psnet.ahrq.gov/issue/preventing-wrong-site-surgery-minnesota-5-year-journey
December 19, 2007 - Discussing a 5-year effort to report , analyze, and reduce wrong-site procedures , this magazine article details
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psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
January 01, 2020 - diabetes technology may have
contributed to avoidable hyperglycemia after acute
stroke
4
Case Details … numbness
– Head CT was normal
– Transferred to academic medical center for further management
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Case Details … high dose steroids and three rounds of plasmapheresis
• Discharged home three weeks later
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Case Details
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psnet.ahrq.gov/node/44949/psn-pdf
February 01, 2019 - Please refer to the information link below for further details.
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psnet.ahrq.gov/node/44688/psn-pdf
February 23, 2018 - Summarizing the goals from the report, this commentary details how the recommendations from
the NAM
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psnet.ahrq.gov/node/41132/psn-pdf
March 13, 2012 - The article details how stratiegies for communication, local adaptation, teamwork, and
learning from
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psnet.ahrq.gov/issue/medication-management-detailed-use-case
June 29, 2016 - Book/Report
Medication Management: Detailed Use Case.
Citation Text:
Medication Management: Detailed Use Case. Washington, DC: Office of the National Coordinator for Health Information Technology, US Department of Health and Human Services; 2007.
Copy Citation
Sav…
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - abdominal pain, and how to mitigate the influence of cognitive biases in the diagnostic process.
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Case Details … Case Details
The physical exam was notable for guarding and a small periumbilical knot, which was not … Case Details
While awaiting test results, the ED physician ordered a “GI cocktail,” which provided no … Case Details
The following day, the patient’s wife took him to another ED with similar symptoms, but … Case Details
Laboratory test results were also similar except that the hemoglobin was even higher as
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psnet.ahrq.gov/glossary/handoffs-and-handovers
September 13, 2021 - The summary may leave out key details due to oversight, exacerbated by an unstructured process and being
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psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
January 01, 2020 - A case describing how care inconsistent with patient
goals can lead to preventable harm
4
Case Details … he continued to require intermittent high flow
oxygen or BIPAP to maintain oxygenation
5
Case Details … and discharge planner worked with social
services agency to coordinate the transfer home
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Case Details … status and plan
for home hospice care and felt no further interventions would be required
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Case Details
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - For this reason, the responsibility
of obtaining such details falls on both the surgical and anesthesia … The details of the case should be recorded online so that this information can be
accessed by future … Difficult Airway.”17 The
patient sometimes only remembers that there was a problem but does not recall the details … Giving the
patient a card with the access details for the online difficult airway registry and a MedicAlert
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psnet.ahrq.gov/issue/reduce-readmissions-pharmacy-programs-focus-transitions-hospital-community
September 26, 2016 - This article details how a community liaison pharmacist who works with clinicians in hospitals can help
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psnet.ahrq.gov/issue/cardiac-arrest-during-anesthesia
January 19, 2011 - This article reviews factors contributing to anesthesia-related cardiac arrests and details prevention