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41. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records | PSNet
    psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
    February 01, 2023 - Am J Med . 2022;135(7):840-843. [ Free full text ] Nijor S, Rallis G, Lad N, et al. … JAMA. 2018;319(12):1276–1278. [ Free full text ] Wright A, Aaron S, Seger DL, et al. … Accessed on July 24, 2023. [ Free full text ] Bartlelt K, Joyce B, McCaffrey K, et al. … [ Free full text ] Stetson PD, Bakken S, Wrenn JO, et al. … J Am Med Inform Assoc . 2011;18(2):112-117. [ Free full text Sallam M.

42. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
    January 01, 2023 - [Free full text] 6. Bone RC, Balk RA, Cerra FB, et al. … [Free full text] 12. Kumar A, Roberts D, Wood KE, et al. … [Free full text] 18. Shin R, Lee SM, Sohn B, et al. … [Free full text] 24. Lee DB, Shin S, Yang CS. … [Free full text] 26. Moore LJ, Moore FA.

43. Medication Safety Events Related to Diagnostic Imaging | PSNet
    psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
    January 26, 2022 - Accessed May 4, 2022. [ Free full text ] Chung F, Abdullah HR, Liao P. … Chest . 2016;149(3):631-638. [ Free full text ] Green SM, Mason KP, Krauss BS. … [ Free full text ] American Society of Anesthesiologists. … Accessed May 5, 2022. [ Free full text ] Somogyi AA, Barratt DT, Coller JK. … [ Free full text ]  Munn Z, Jordan Z.

44. Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
    January 01, 2023 - [Free full text] 6. Liu RT, Bettis AH, Burke TA. … [Free full text] 7. Köhne ACJ, Isvoranu AM. … [Free full text] 8. Grilo CM, Udo T. … [Free full text] 11. Ghosh T, Bol K, Butler M, et al. … [Free full text]

45. Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
    January 01, 2022 - Free full text 11. Kroenke K, Alford DP, Argoff C, et al. … Free full text 13. … Free full text 16. Qaseem A, Wilt TJ, McLean RM, et al. … Free full text 17. Chou R, Deyo R, Friedly J, et al. … Free full text

46. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. | PSNet
    psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
    November 08, 2023 - Curr Anesthesiol Rep. 2017;7:320-329. [ Free full text ] Meyer T. … [ Free full text ] Wahr JA, Abernathy JH 3rd, Lazarra EH, et al. … Br J Anaesth . 2017;118(1):32-43 . [ Free full text ] Eichhorn, JE. … Accessed January 25, 2024. [ Free full text ] Spath PL.  … BMJ . 2011;343:1-14. [ Free full text ] Green M, Tariq R, Green P.

47. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
    January 01, 2021 - [Free full text] 10. Rabow M, Kvale E, Barbour L, et al. … [Free full text] 12. Harrison KL, Connor SR. … [Free full text] 13. … [Free full text] 22. Bomba PA, Morrissey MB, Leven DC. … [Free full text] 28. Kass-Bartelmes BL, Hughes R.

48. The Need to Eat | PSNet
    psnet.ahrq.gov/web-mm/need-eat
    April 05, 2006 - [Full free text] Committee ASoA. … [Full free text] Doley J, Phillips W. … [Full free text] McFadden C. … [Full free text] Mordarski BA, Hand RK. … [Full free text] Arendt SW, Gregoire MB.

49. Critical Echocardiogram Result Lost to Follow-up. | PSNet
    psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
    July 31, 2023 - OEI-06-09-00090. [ Free full text (PDF) ] de Vries EN, Ramrattan MA, Smorenburg SM, et al. … BMJ. 2019;366:l4185. [ Free full text ] Bates DW, Levine DM, Salmasian H, et al. … OEI-06-08-00220. [ Free full text (PDF) ] Transition of Care. … [Free full text ] Rennke S, Nguyen OK, Shoeb MH, et al. … PLoS One . 2018;13(2):e0191980. [ Free full text ] Kelly KJ, Doucet S, Luke A.

50. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery. | PSNet
    psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
    August 30, 2023 - Accessed March 3, 2023.[ Free full text ] Martineau M, Nelson-Piercy C. … Accessed March 3, 2023. [ Free full text ] Smiley RM, Friedman AM. … BMJ . 2013;347:f6099. [ Free full text Bates SM, Greer IA, Middeldorp S, et al. … Accessed March 3, 2023. [ Free full text ] Guglielminotti J, Li G. … Accessed March 3, 2023. [ Free full text ]. Dillon S.

51. Digital Health Literacy | PSNet
    psnet.ahrq.gov/primer/digital-health-literacy
    August 30, 2023 - Prim Care . 2022;49(4):517-530. [ Free full text ] Swire-Thompson B, Lazer D. … Annu Rev Public Health . 2020;41:433-451. [ Free full text ] Digital Literacy. … Health Commun . 2018;33(12):1410-1424. [ Free full text ] Cheng C, Gearon E, Hawkins M, et al. … Front Public Health . 2023;11:1229734. [ Free full text ] Neter E, Brainin E. … [ Free full text ] Jackson DN, Trivedi N, Baur C.

52. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings | PSNet
    psnet.ahrq.gov/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
    October 30, 2019 - Psychiatric News . [ Free full text ]Accessed December 17, 2021. … Health Aff (Millwood). 2016;35(6):1084-1090. [ Free full text ] Caldwell B. … JAMA Netw Open. 2020;3(10):e2022713-e2022713. [ Free full text ] Rozel JS. … Acad Emerg Med. 2021;28(6):705-706. [ Free full text ] Miller M, Hemenway D. … Spring 2008. [ Free full text ]Accessed December 17, 2021. Bhatia R.

53. Deprescribing as a Patient Safety Strategy | PSNet
    psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
    September 07, 2019 - Free full text Maher Jr. RL, Hanlon JT, Hajjar ER. … Expert Opin Drug Saf. 2014;13(1). doi: 10.1517/14740338.2013.827660  Free full text Leelakanok N, … Drugs Aging . 2013;30(11). doi: 1 0.1007/s40266-013-0118-4  Free full text Farrell B, Mangin D. … Free full text Reeve E. … Free full text Bloomfield HE, Greer N, Linsky AM, et al.

54. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. | PSNet
    psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
    October 31, 2023 - Clin Drug Investig . 2013;33(6):401-408.[ Free full text ] Bookwalter T, Gitlin M. … Ann Intern Med . 2002;137(1):74. [ Free full text ] Miller A, Price G. … Accessed December 2022. [ Free full text ] Lyrica [full prescribing information]. … Accessed December 15, 2022 [ Free full text ] Klimas R, Mikus G. … Accessed May 17, 2021. [ Free full text [PDF) ] Baker M, Perazella MA.

55. Microsoft PowerPoint - Spotlight Case_Hindsight is 2020_SLIDES_FINAL.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_hindsight_is_2020_slides_final.pdf
    January 01, 2024 - [Free full text] 2. Bakradze E, Liberman AL. … [Free full text] 5. Hassing LT, Verschoof MA, Koppen H. … [Free full text] 14. Lee VH, Howell R, Yadav R, et al. … [Free full text] 20. … [Free full text] 21. Kahneman D, Klein G.

56. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! | PSNet
    psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
    February 01, 2023 - Acta Diabetol . 1993;30(4):251-253. [ Free full text ] Plewa MC, Bryant M, King-Thiele R. … Cureus . 2022;14(9):e29652. [ Free full text ] Juneja D, Nasa P, Jain R, et al. … Endocr Pract . 2022;28(9):884-888. [ Free full text ] Drug Safety Communication. … Accessed November 29, 2023. [ Free full text ] Pujara S, Ioachimescu A. … Can J Anaesth . 2018;65(2):188-193. [ Free full text ] Khalifa M, Aftab H, Kantorovich V.

57. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon | PSNet
    psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
    January 29, 2021 - Front Public Health . 2022;10:818816. [ Free full text ] Sharma S, Arora L. … Accessed November 29, 2023. [ Free full text ] Bohringer C, Liu H. … J Biomed Res. 201;33(4):217–220. [ Free full text ] Murphy GS, Brull SJ. … Obes Surg . 2020;30(9):3354-3362. [ Free full text ] Pitlick MM, Volcheck GW. … Core Evid . 2013;8:57-67. [ Free full text ] Honing G, Martini CH, Bom A, et al.

58. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
    January 01, 2023 - [Free full text] 10. Kern J, Guinn A, Mehta P. … [Free full text] 14. Elikashvili I, Vella AE. … [Free full text] 20. Clay-Williams R, Colligan L. … [Free full text] 21. Treadwell JR, Lucas S, Tsou AY. … [Free full text] 34. Neuspiel DR, Taylor MM.

59. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet
    psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
    April 10, 2024 - Acad Emerg Med . 2007;14(1):41-44. [ Free full text ] Kern J, Guinn A, Mehta P. … West J Emerg . 2013;14(1):47–54. [ Free full text ] Clay-Williams R, Colligan L. … Ann Pharmacother .2006;40(10):1766–1776. [ Free full text ] Hanna GM, Levine WC. … Accessed April 4, 2023. [ Free full text ] Adapa RM, Mani V, Murray LJ, et al. … Ann Emerg Med. 2015;66(2):97-106.e3. [ Free full text ] Neuspiel DR, Taylor MM.

60. Preventable Transfer to the Hospital | PSNet
    psnet.ahrq.gov/web-mm/preventable-transfer-hospital
    March 31, 2022 - Innov Aging . 2017;1(1):igx012. [ Free full text ] McMahan RD, Tellez I, Sudore RL. … J Am Geriatr Soc . 2021;69(1):234-244. [ Free full text ] Carr D, Kalousova L, Lin K, et al. … Soc Sci Med . 2021;272:113730. [ Free full text ] Courtwright AM, Abrams J, Robinson EM. … J Bioeth Inq . 2017;14(2):241-250. [ Free full text ] Britton MC, Ouellet GM, Minges KE, et al. … Jt Comm J Qual Patient Saf. 2017;43(11):565-572. doi: 10.1016/j.jcjq.2017.06.004. [ Free full text