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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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.…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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.…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. psnet.ahrq.gov/curated-library/maternal-safety
    January 31, 2024 - This prospective study evaluated a maternal early warning trigger tool that was internally developed
  11. 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
  12. 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.
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49431/psn-pdf
    January 01, 2004 - Currently the use of D-dimer is being evaluated for this purpose.
  14. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
  15. 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. Copy Citation Format: Google Scholar BibT…
  16. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  17. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. 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

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