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psnet.ahrq.gov/node/39463/psn-pdf
February 10, 2015 - Mixed results in the safety performance of computerized
physician order entry.
February 10, 2015
Metzger J, Welebob E, Bates DW, et al. Mixed results in the safety performance of computerized physician
order entry. Health Aff (Millwood). 2010;29(4):655-663. doi:10.1377/hlthaff.2010.0160.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/41458/psn-pdf
June 19, 2012 - What stops hospital clinical staff from following
protocols? An analysis of the incidence and factors
behind the failure of bedside clinical staff to activate the
rapid response system in a multi-campus Australian
metropolitan healthcare service.
June 19, 2012
Shearer B, Marshall S, Buist MD, et al. What stops ho…
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psnet.ahrq.gov/node/39604/psn-pdf
November 23, 2016 - Improving the patient, family, and clinician experience
after harmful events: the "When Things Go Wrong"
curriculum.
November 23, 2016
Bell SK, Moorman D, Delbanco T. Improving the patient, family, and clinician experience after harmful
events: the "when things go wrong" curriculum. Acad Med. 2010;85(6):1010-1017.…
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psnet.ahrq.gov/node/46704/psn-pdf
December 04, 2018 - Surveying care teams after in-hospital deaths to identify
preventable harm and opportunities to improve advance
care planning.
December 4, 2018
Lucier D, Folcarelli P, Totte C, et al. Surveying Care Teams after in-Hospital Deaths to Identify Preventable
Harm and Opportunities to Improve Advance Care Planning. Jt C…
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psnet.ahrq.gov/node/42510/psn-pdf
August 21, 2013 - Root cause analysis reports help identify common factors
in delayed diagnosis and treatment of outpatients.
August 21, 2013
Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in
delayed diagnosis and treatment of outpatients. Health Aff (Millwood). 2013;32(8):1368-75.…
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psnet.ahrq.gov/node/37167/psn-pdf
February 03, 2011 - Mortality among patients in VA hospitals in the first 2
years following ACGME resident duty hour reform.
February 3, 2011
Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among patients in VA hospitals in the first 2 years
following ACGME resident duty hour reform. JAMA. 2007;298(9):984-92.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/44976/psn-pdf
February 14, 2017 - Do patients' disruptive behaviours influence the accuracy
of a doctor's diagnosis? A randomised experiment.
February 14, 2017
Schmidt HG, Van Gog T, Schuit SC, et al. Do patients' disruptive behaviours influence the accuracy of a
doctor's diagnosis? A randomised experiment. BMJ Qual Saf. 2017;26(1):19-23. doi:10.11…
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psnet.ahrq.gov/node/43643/psn-pdf
November 04, 2014 - Out-of-hospital medication errors among young children
in the United States, 2002–2012.
November 4, 2014
Smith MD, Spiller HA, Casavant MJ, et al. Out-of-hospital medication errors among young children in the
United States, 2002-2012. Pediatrics. 2014;134(5):867-76. doi:10.1542/peds.2014-0309.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/44721/psn-pdf
August 20, 2016 - Tall Man lettering and potential prescription errors: a time
series analysis of 42 children's hospitals in the USA over
9 years.
August 20, 2016
Zhong W, Feinstein JA, Patel NS, et al. Tall Man lettering and potential prescription errors: a time series
analysis of 42 children's hospitals in the USA over 9 years. B…
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psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - This prospective study evaluated a maternal early warning trigger tool that was internally developed
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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - evidence of efficacy for this off-label indication.1
10
Background (2)
• It is unknown if the staff evaluated
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - Currently the use of D-dimer is being evaluated for this purpose.
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - Currently the use of D-dimer is being
evaluated for this purpose.
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/consequences-medical-overuse
May 05, 2021 - SPOTLIGHT CASE
Consequences of Medical Overuse
Citation Text:
Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - SPOTLIGHT CASE
Isolated Clot, Real Error
Citation Text:
Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - SPOTLIGHT CASE
The Wet Read
Citation Text:
Arenson RL. The Wet Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/node/60329/psn-pdf
May 14, 2020 - In Conversation With... Joel Willis, DO, PA, MA, MPhiL
and Neal Sikka, MD
May 14, 2020
In Conversation With.. Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
Editor’s note: Joel Willis, DO, PA, M…
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - Delayed Diagnosis of Mesenteric Ischemia
August 31, 2022
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for…
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - • Upon presentation, the patient was evaluated by the intensivist team who
recommended admission