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4761. Psn-Pdf (pdf file)
      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…

4762. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49397/psn-pdf
      May 01, 2003 - The Dropped Lung May 1, 2003 Heffner JR. The Dropped Lung. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dropped-lung The Case A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…

4763. Critical Opportunity Lost | PSNet
      psnet.ahrq.gov/web-mm/critical-opportunity-lost
      February 17, 2017 - Critical Opportunity Lost Citation Text: Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

4764. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49776/psn-pdf
      November 01, 2016 - Continuity Errors in Resident Clinic November 1, 2016 Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic The Case A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty concentrating. …

4765. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851389/psn-pdf
      July 31, 2023 - event, which BWH researchers believe was in alignment with current national standards of care, was evaluated

4766. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867599/psn-pdf
      January 22, 2025 - Assessing patient work system factors for medication management during transition of care among older adults: an observational study. January 22, 2025 Xiao Y, Hsu Y-J, Hannum SM, et al. Assessing patient work system factors for medication management during transition of care among older adults: an observational st…

4767. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73445/psn-pdf
      June 30, 2021 - Moving beyond the weekend effect: how can we best target interventions to improve patient care? June 30, 2021 Marang-van de Mheen PJ, Vincent CA. Moving beyond the weekend effect: how can we best target interventions to improve patient care? BMJ Qual Saf. 2021;30(7):525-528. doi:10.1136/bmjqs-2020- 012620. https:…

4768. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45538/psn-pdf
      December 14, 2016 - Liquid medication errors and dosing tools: a randomized controlled experiment. December 14, 2016 Yin S, Parker RM, Sanders LM, et al. Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment. Pediatrics. 2016;138(4):e20160357. https://psnet.ahrq.gov/issue/liquid-medication-errors-and-dosing-to…

4769. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73287/psn-pdf
      May 19, 2021 - Influence of opioid prescription policy on overdoses and related adverse effects in a primary care population. May 19, 2021 Harder VS, Plante TB, Koh I, et al. Influence of opioid prescription policy on overdoses and related adverse effects in a primary care population. J Gen Intern Med. 2021;36(7):2013-2020. doi:1…

4770. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44965/psn-pdf
      February 15, 2017 - Identification and Prioritization of Health IT Patient Safety Measures. February 15, 2017 Washington, DC: National Quality Forum; February 2016. https://psnet.ahrq.gov/issue/identification-and-prioritization-health-it-patient-safety-measures Health information technology (IT) has transformed health care and improv…

4771. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851360/psn-pdf
      July 12, 2023 - How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care. July 12, 2023 Khazen M, Sullivan EE, Arabadjis S, et al. How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care. BMJ Open. 2023;13(5):e071241. doi:10.1136/b…

4772. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38428/psn-pdf
      February 18, 2009 - Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties. February 18, 2009 Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220. https://psnet.ahrq.gov/issue/adverse-eve…

4773. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837628/psn-pdf
      July 06, 2022 - Multilevel factors associated with time to biopsy after abnormal screening mammography results by race and ethnicity. July 6, 2022 Lawson MB, Bissell MCS, Miglioretti DL, et al. Multilevel factors associated with time to biopsy after abnormal screening mammography results by race and ethnicity. JAMA Oncol. 2022;8(…

4774. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851054/psn-pdf
      June 28, 2023 - Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review. June 28, 2023 Ayre MJ, Lewis PJ, Keers RN. Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review. BMC Psychiatry. 2023;23(1):417. doi:10.118…

4775. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36544/psn-pdf
      July 14, 2010 - Targeted chart review of pediatric patient safety events identified by the Agency for Healthcare Research and Quality's Patient Safety Indicators methodology. July 14, 2010 Scanlon M, Miller MR, Harris JM, et al. Targeted Chart Review of Pediatric Patient Safety Events Identified by the Agency for Healthcare Resea…

4776. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48123/psn-pdf
      August 28, 2019 - Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit. August 28, 2019 Orenstein EW, Ferro DF, Bonafide CP, et al. JAMIA Open. 2019;2(3):392-398. https://psnet.ahrq.gov/issue/hidden-health-it-hazards-qualitative-an…

4777. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44646/psn-pdf
      November 11, 2015 - The hidden costs of reconciling surgical sponge counts. November 11, 2015 Steelman VM, Schaapveld AG, Perkhounkova Y, et al. The Hidden Costs of Reconciling Surgical Sponge Counts. AORN J. 2015;102(5):498-506. doi:10.1016/j.aorn.2015.09.002. https://psnet.ahrq.gov/issue/hidden-costs-reconciling-surgical-sponge-coun…

4778. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45120/psn-pdf
      September 11, 2016 - Saving lives: a meta-analysis of team training in healthcare. September 11, 2016 Hughes A, Gregory ME, Joseph DL, et al. Saving lives: A meta-analysis of team training in healthcare. J Appl Psychol. 2016;101(9):1266-304. doi:10.1037/apl0000120. https://psnet.ahrq.gov/issue/saving-lives-meta-analysis-team-training-…

4779. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842430/psn-pdf
      September 05, 2018 - The Safety of Intravenous Drug Delivery Systems: Update on Current Issues Since the 2009 Consensus Development Conference. September 5, 2018 Rodriguez R. The Safety of Intravenous Drug Delivery Systems: Update on Current Issues Since the 2009 Consensus Development Conference. Hosp Pharm. 2018;53(6):408-414. doi:10…

4780. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35572/psn-pdf
      February 03, 2011 - The long road to patient safety: a status report on patient safety systems. February 3, 2011 Longo DR, Hewett JE, Ge B, et al. The long road to patient safety: a status report on patient safety systems. JAMA. 2005;294(22):2858-65. https://psnet.ahrq.gov/issue/long-road-patient-safety-status-report-patient-safety-s…