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psnet.ahrq.gov/issue/effect-admission-medication-reconciliation-adverse-drug-events-admission-medication-changes
April 12, 2019 - June 13, 2011
Medication details documented on hospital discharge: cross-sectional observational
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psnet.ahrq.gov/issue/impact-medication-reconciliation-improving-transitions-care
June 19, 2019 - March 1, 2023
Medication details documented on hospital discharge: cross-sectional observational
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psnet.ahrq.gov/node/37262/psn-pdf
December 19, 2011 - Academic detailing to improve laboratory testing among
outpatient medication users.
December 19, 2011
Lafata JE, Gunter MJ, Hsu J, et al. Academic detailing to improve laboratory testing among outpatient
medication users. Med Care. 2007;45(10):966-72.
https://psnet.ahrq.gov/issue/academic-detailing-improve-laborat…
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
January 01, 2024 - and summarizing
strategies to identify “stroke mimics” and improve stroke
diagnosis.
4
Case Details … droop, but facial symmetry was
difficult to assess as he would not follow instructions.
5
Case Details … findings represented a National Institutes of Health
Stroke Scale (NIHSS) value of 6.
6
Case Details … – TNKase was administered and he was monitored per hospital protocol.
7
Case Details (4)
• Thirty
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psnet.ahrq.gov/issue/computerized-prescribing-alerts-and-group-academic-detailing-reduce-use-potentially
July 10, 2008 - Study
Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people.
Citation Text:
Simon SR, Smith DH, Feldstein AC, et al. Computerized prescribing alerts and group academic detailing to reduce the use of poten…
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psnet.ahrq.gov/node/60707/psn-pdf
July 22, 2020 - The devil is in the detail: how a closed-loop
documentation system for IV infusion administration
contributes to and compromises patient safety.
July 22, 2020
Furniss D, Dean Franklin B, Blandford A. The devil is in the detail: how a closed-loop documentation
system for IV infusion administration contributes to an…
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psnet.ahrq.gov/node/36168/psn-pdf
August 31, 2011 - Computerized prescribing alerts and group academic
detailing to reduce the use of potentially inappropriate
medications in older people.
August 31, 2011
Simon SR, Smith DH, Feldstein AC, et al. Computerized prescribing alerts and group academic detailing to
reduce the use of potentially inappropriate medications i…
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery
4
4
Case Details … Her neurological and mental status examinations were documented as normal.
5
5
Case Details (2)
Within … Nurses continued to report that she was intermittently uncommunicative with a “fixed” gaze.
6
6
Case Details
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psnet.ahrq.gov/issue/evaluation-adverse-drug-events-and-medication-discrepancies-transitions-care-between-hospital
June 07, 2023 - August 24, 2011
Medication details documented on hospital discharge: cross-sectional
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psnet.ahrq.gov/issue/interventions-reduce-adverse-drug-event-related-outcomes-older-adults-systematic-review-and
July 19, 2023 - December 29, 2014
Medication details documented on hospital discharge: cross-sectional
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psnet.ahrq.gov/issue/effects-adverse-drug-event-alert-system-cost-and-quality-outcomes-community-hospitals
February 17, 2021 - November 17, 2010
Medication details documented on hospital discharge: cross-sectional
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psnet.ahrq.gov/node/41220/psn-pdf
March 14, 2012 - Surgical checklists: a detailed review of their emergence,
development, and relevance to neurosurgical practice.
March 14, 2012
McConnell DJ, Fargen KM, Mocco J. Surgical checklists: A detailed review of their emergence,
development, and relevance to neurosurgical practice. Surg Neurol Int. 2012;3:2. doi:10.4103/21…
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - monitoring endotracheal
and tracheostomy tube balloon pressures to avoid tissue necrosis
4
Case Details … The
tracheostomy tube was secured, inspected via bronchoscopy, and properly
sutured.
5
Case Details … ultimately leading to hypotension and requiring 100%
inhaled oxygen via the ventilator.
6
Case Details
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psnet.ahrq.gov/web-mm/techno-trip
May 01, 2005 - The Syndrome of IT Dependence The details of digital radiology and IT are only one aspect of this interesting … We can only speculate because the details are unavailable, but the critical issue is that the neurosurgeon … As for countermeasures, our attention is initially drawn to the details of the computer systems and their
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psnet.ahrq.gov/issue/effect-hospital-acquired-clostridium-difficile-infection-hospital-mortality
April 22, 2011 - April 20, 2011
Medication details documented on hospital discharge: cross-sectional observational
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psnet.ahrq.gov/issue/clinical-evaluation-ade-scorecards-decision-support-tool-adverse-drug-event-analysis-and
December 31, 2014 - March 23, 2011
Medication details documented on hospital discharge: cross-sectional observational
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psnet.ahrq.gov/issue/potential-costs-and-consequences-associated-medication-error-hospital-discharge-expert
September 05, 2018 - January 25, 2023
Medication details documented on hospital discharge: cross-sectional
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psnet.ahrq.gov/issue/medication-regimen-complexity-and-hospital-readmission-adverse-drug-event
December 03, 2014 - June 13, 2011
Medication details documented on hospital discharge: cross-sectional observational
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psnet.ahrq.gov/issue/accuracy-medication-documentation-hospital-discharge-summaries-retrospective-analysis
March 23, 2012 - April 14, 2011
Medication details documented on hospital discharge: cross-sectional observational
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psnet.ahrq.gov/issue/medicare-payment-selected-adverse-events-building-business-case-investing-patient-safety
September 18, 2009 - Resources
Medicare's decision to withhold payment for hospital errors: the devil is in the details