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  1. psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
    September 16, 2015 - SPOTLIGHT CASE Which Line: Ordering Provider or Proceduralist? Citation Text: Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …
  2. psnet.ahrq.gov/web-mm/dissecting-presentation
    May 05, 2021 - SPOTLIGHT CASE Dissecting the Presentation Citation Text: Suat-Ooi SB. Dissecting the Presentation. 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 …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49445/psn-pdf
    May 01, 2004 - No Blood, Please May 1, 2004 Liang BA. No Blood, Please. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/no-blood-please The Case A young woman, about 30 years of age, was injured in an automobile collision. She was brought to the emergency department (ED) via ambulance, where she was found to be suffering …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866839/psn-pdf
    September 25, 2024 - Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations September 25, 2024 Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/errors-managing-open-wound-elb…
  5. psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
    January 01, 2024 - Spotlight Spotlight Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations 1 Source and Credits This presentation is based on the September 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: David…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61110/psn-pdf
    November 11, 2020 - Association between parent comfort with English and adverse events among hospitalized children. November 11, 2020 Khan A, Yin HS, Brach C, et al. Association between parent comfort with English and adverse events among hospitalized children. JAMA Pediatr. 2020;174(12):e203215. doi:10.1001/jamapediatrics.2020.3215.…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40982/psn-pdf
    March 23, 2012 - Emergency hospitalizations for adverse drug events in older Americans. March 23, 2012 Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency hospitalizations for adverse drug events in older Americans. New Engl J Med. 2011;365(21):2002-2012. doi:10.1056/NEJMsa1103053. https://psnet.ahrq.gov/issue/emergency-hospitali…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38691/psn-pdf
    June 10, 2009 - Effects of shift length on quality of patient care and health provider outcomes: systematic review. June 10, 2009 Estabrooks CA, Cummings GG, Olivo SA, et al. Effects of shift length on quality of patient care and health provider outcomes: systematic review. Qual Saf Health Care. 2009;18(3):181-188. doi:10.1136/qs…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43262/psn-pdf
    April 06, 2015 - Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients. April 6, 2015 Johnston MJ, Arora S, Anderson O, et al. Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients. Ann Surg. 2015;261(5):831-838. doi:…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48083/psn-pdf
    August 07, 2019 - Missed diagnosis of cancer in primary care: insights from malpractice claims data. August 7, 2019 Aaronson E, Quinn GR, Wong CI, et al. Missed diagnosis of cancer in primary care: Insights from malpractice claims data. J Healthc Risk Manag. 2019;39(2):19-29. doi:10.1002/jhrm.21385. https://psnet.ahrq.gov/issue/mis…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36979/psn-pdf
    February 28, 2011 - Changes in outcomes for internal medicine inpatients after work-hour regulations. February 28, 2011 Horwitz LI, Kosiborod M, Lin Z, et al. Changes in outcomes for internal medicine inpatients after work-hour regulations. Ann Intern Med. 2007;147(2):97-103. https://psnet.ahrq.gov/issue/changes-outcomes-internal-med…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46339/psn-pdf
    August 20, 2018 - Association of the Hospital Readmissions Reduction Program implementation with readmission and mortality outcomes in heart failure. August 20, 2018 Gupta A, Allen LA, Bhatt DL, et al. Association of the Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure.…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43346/psn-pdf
    August 02, 2015 - Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy. August 2, 2015 Parsons K, Messer K, Palazzi K, et al. Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy. JAMA Surg. 2014;149(8):845-51. doi:10.1001/jamasurg.2014.31. https:…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43766/psn-pdf
    September 26, 2016 - Driven to distraction: a prospective controlled study of a simulated ward round experience to improve patient safety teaching for medical students. September 26, 2016 Thomas I, Nicol L, Regan L, et al. Driven to distraction: a prospective controlled study of a simulated ward round experience to improve patient saf…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47010/psn-pdf
    March 13, 2019 - Comparative accuracy of diagnosis by collective intelligence of multiple physicians vs individual physicians. March 13, 2019 Barnett ML, Boddupalli D, Nundy S, et al. Comparative Accuracy of Diagnosis by Collective Intelligence of Multiple Physicians vs Individual Physicians. JAMA Netw Open. 2019;2(3):e190096. do…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46191/psn-pdf
    July 19, 2017 - Performance of a trigger tool for identifying adverse events in oncology. July 19, 2017 Lipitz-Snyderman A, Classen D, Pfister D, et al. Performance of a Trigger Tool for Identifying Adverse Events in Oncology. J Oncol Pract. 2017;13(3). doi:10.1200/jop.2016.016634. https://psnet.ahrq.gov/issue/performance-trigger…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39210/psn-pdf
    January 12, 2010 - Can aviation-based team training elicit sustainable behavioral change? January 12, 2010 Sax HC, Browne P, Mayewski RJ, et al. Can aviation-based team training elicit sustainable behavioral change? Arch Surg. 2009;144(12):1133-1137. doi:10.1001/archsurg.2009.207. https://psnet.ahrq.gov/issue/can-aviation-based-team…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853427/psn-pdf
    January 01, 2024 - Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis. September 13, 2023 Bell SK, Harcourt K, Dong J, et al. Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a m…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/856584/psn-pdf
    January 01, 2024 - Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents from the National Reporting and Learning System (NRLS). November 29, 2023 Ravindran S, Matharoo M, Rutter MD, et al. Patient safety incidents in endoscopy: a human factors analysis of nonprocedural signific…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44683/psn-pdf
    June 21, 2016 - Physician spending and subsequent risk of malpractice claims: observational study. June 21, 2016 Jena AB, Schoemaker L, Bhattacharya J, et al. Physician spending and subsequent risk of malpractice claims: observational study. BMJ. 2015;351:h5516. doi:10.1136/bmj.h5516. https://psnet.ahrq.gov/issue/physician-spendi…

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