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psnet.ahrq.gov/node/38606/psn-pdf
January 02, 2017 - Using an electronic prescribing system to ensure
accurate medication lists in a large multidisciplinary … Using an electronic prescribing system to ensure accurate medication lists in a
large multidisciplinary … https://psnet.ahrq.gov/issue/using-electronic-prescribing-system-ensure-accurate-medication-lists-large … https://psnet.ahrq.gov/issue/using-electronic-prescribing-system-ensure-accurate-medication-lists-large-multidisciplinary … https://psnet.ahrq.gov/issue/using-electronic-prescribing-system-ensure-accurate-medication-lists-large-multidisciplinary
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psnet.ahrq.gov/node/38869/psn-pdf
August 19, 2009 - Frequency and severity of harm of medication errors
related to the parenteral nutrition process in a large … Frequency and severity of harm of medication errors related to the
parenteral nutrition process in a large … psnet.ahrq.gov/issue/frequency-and-severity-harm-medication-errors-related-parenteral-nutrition-
process-large … psnet.ahrq.gov/issue/frequency-and-severity-harm-medication-errors-related-parenteral-nutrition-process-large … psnet.ahrq.gov/issue/frequency-and-severity-harm-medication-errors-related-parenteral-nutrition-process-large
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psnet.ahrq.gov/node/41953/psn-pdf
June 19, 2013 - Potentially inappropriate medications in a large cohort of
patients in geriatric units: association … Potentially inappropriate medications in a large cohort of patients in
geriatric units: association … https://psnet.ahrq.gov/issue/potentially-inappropriate-medications-large-cohort-patients-geriatric-units … https://psnet.ahrq.gov/issue/potentially-inappropriate-medications-large-cohort-patients-geriatric-units-association … https://psnet.ahrq.gov/issue/potentially-inappropriate-medications-large-cohort-patients-geriatric-units-association
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psnet.ahrq.gov/node/42396/psn-pdf
July 31, 2013 - Developing and implementing a standardized process for
Global Trigger Tool application across a large … Developing and implementing a standardized process for global
trigger tool application across a large … psnet.ahrq.gov/issue/developing-and-implementing-standardized-process-global-trigger-tool-
application-across-large … This study describes how a large health system used the Global
Trigger Tool to identify causes of preventable … psnet.ahrq.gov/issue/developing-and-implementing-standardized-process-global-trigger-tool-application-across-large
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psnet.ahrq.gov/node/42931/psn-pdf
April 20, 2014 - Assigning a team-based pager for on-call physicians
reduces paging errors in a large academic hospital … Assigning a team-based pager for on-call physicians reduces paging errors in
a large academic hospital … https://psnet.ahrq.gov/issue/assigning-team-based-pager-call-physicians-reduces-paging-errors-large- … https://psnet.ahrq.gov/issue/assigning-team-based-pager-call-physicians-reduces-paging-errors-large-academic-hospital … https://psnet.ahrq.gov/issue/assigning-team-based-pager-call-physicians-reduces-paging-errors-large-academic-hospital
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psnet.ahrq.gov/node/43515/psn-pdf
July 03, 2016 - Targeting improvements in patient safety at a large
academic center: an institutional handoff curriculum … Targeting improvements in patient safety at a large academic center: an
institutional handoff curriculum … https://psnet.ahrq.gov/issue/targeting-improvements-patient-safety-large-academic-center-institutional … https://psnet.ahrq.gov/issue/targeting-improvements-patient-safety-large-academic-center-institutional-handoff-curriculum … https://psnet.ahrq.gov/issue/targeting-improvements-patient-safety-large-academic-center-institutional-handoff-curriculum
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psnet.ahrq.gov/node/37909/psn-pdf
February 23, 2009 - Prevalence of adverse drug combinations in a large post-
mortem toxicology database. … Prevalence of adverse drug combinations in a large post-mortem
toxicology database. … https://psnet.ahrq.gov/issue/prevalence-adverse-drug-combinations-large-post-mortem-toxicology-
database … https://psnet.ahrq.gov/issue/prevalence-adverse-drug-combinations-large-post-mortem-toxicology-database … https://psnet.ahrq.gov/issue/prevalence-adverse-drug-combinations-large-post-mortem-toxicology-database
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psnet.ahrq.gov/node/37409/psn-pdf
March 28, 2012 - Extent, nature and consequences of adverse events:
results of a retrospective casenote review in a large … Extent, nature and consequences of adverse events: results of a
retrospective casenote review in a large … psnet.ahrq.gov/issue/extent-nature-and-consequences-adverse-events-results-retrospective-
casenote-review-large-nhs … psnet.ahrq.gov/issue/extent-nature-and-consequences-adverse-events-results-retrospective-casenote-review-large-nhs … psnet.ahrq.gov/issue/extent-nature-and-consequences-adverse-events-results-retrospective-casenote-review-large-nhs
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psnet.ahrq.gov/node/46025/psn-pdf
July 11, 2017 - Measuring to improve medication reconciliation in a large
subspecialty outpatient practice. … Measuring to Improve Medication Reconciliation in a Large
Subspecialty Outpatient Practice. … https://psnet.ahrq.gov/issue/measuring-improve-medication-reconciliation-large-subspecialty-outpatient … https://psnet.ahrq.gov/issue/measuring-improve-medication-reconciliation-large-subspecialty-outpatient-practice … https://psnet.ahrq.gov/issue/measuring-improve-medication-reconciliation-large-subspecialty-outpatient-practice
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psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based
April 08, 2018 - Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large … Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based … Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based … patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large … March 1, 2023
WebM&M Cases
Missing a Large Vessel Occlusion
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psnet.ahrq.gov/node/35157/psn-pdf
August 05, 2009 - Safe medication prescribing: training and experience of
medical students and housestaff at a large teaching … Safe medication prescribing: training and experience of medical
students and housestaff at a large teaching … psnet.ahrq.gov/issue/safe-medication-prescribing-training-and-experience-medical-students-and-
housestaff-large … psnet.ahrq.gov/issue/safe-medication-prescribing-training-and-experience-medical-students-and-housestaff-large … psnet.ahrq.gov/issue/safe-medication-prescribing-training-and-experience-medical-students-and-housestaff-large
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psnet.ahrq.gov/node/46223/psn-pdf
June 14, 2017 - Patient-reported safety incidents in older patients with
long-term conditions: a large cross-sectional … Patient-reported safety incidents in older patients with long-term
conditions: a large cross-sectional … https://psnet.ahrq.gov/issue/patient-reported-safety-incidents-older-patients-long-term-conditions-large … https://psnet.ahrq.gov/issue/patient-reported-safety-incidents-older-patients-long-term-conditions-large-cross-sectional … https://psnet.ahrq.gov/issue/patient-reported-safety-incidents-older-patients-long-term-conditions-large-cross-sectional
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psnet.ahrq.gov/node/45961/psn-pdf
June 23, 2017 - Burden of hospitalizations related to adverse drug events
in the USA: a retrospective analysis from large … Burden of hospitalizations related to adverse drug events in the
USA: a retrospective analysis from large … psnet.ahrq.gov/issue/burden-hospitalizations-related-adverse-drug-events-usa-retrospective-
analysis-large … psnet.ahrq.gov/issue/burden-hospitalizations-related-adverse-drug-events-usa-retrospective-analysis-large … psnet.ahrq.gov/issue/burden-hospitalizations-related-adverse-drug-events-usa-retrospective-analysis-large
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psnet.ahrq.gov/node/34654/psn-pdf
June 16, 2011 - Risk mitigation in large scale systems: lessons from high
reliability organizations. … https://psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations … They describe effective techniques in risk mitigation that can be
employed in other large-scale systems … Finally, large-scale systems need to maintain strong safety cultures and norms that reinforce
common … https://psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations
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psnet.ahrq.gov/node/42697/psn-pdf
December 05, 2013 - An initiative to improve the management of clinically
significant test results in a large health care … An initiative to improve the management of clinically significant
test results in a large health care … https://psnet.ahrq.gov/issue/initiative-improve-management-clinically-significant-test-results-large-health … https://psnet.ahrq.gov/issue/initiative-improve-management-clinically-significant-test-results-large-health-care-network … https://psnet.ahrq.gov/issue/initiative-improve-management-clinically-significant-test-results-large-health-care-network
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psnet.ahrq.gov/node/44001/psn-pdf
May 06, 2015 - Wrong-site nerve blocks: 10 yr experience in a large
multihospital health-care system. … Wrong-site nerve blocks: 10 yr experience in a large multihospital
health-care system. … https://psnet.ahrq.gov/issue/wrong-site-nerve-blocks-10-yr-experience-large-multihospital-health-care … https://psnet.ahrq.gov/issue/wrong-site-nerve-blocks-10-yr-experience-large-multihospital-health-care-system … https://psnet.ahrq.gov/issue/wrong-site-nerve-blocks-10-yr-experience-large-multihospital-health-care-system
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psnet.ahrq.gov/issue/funding-announcement-projects-targeting-reduction-healthcare-associated-infections
August 01, 2012 - AHRQ seeks to support large research (R01) and dissemination (R18) projects working to develop strategies … Large Research Projects (R01) (PA-21-265)
Large Health Services Research Demonstration and Dissemination
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psnet.ahrq.gov/issue/impact-inpatient-harms-hospital-finances-and-patient-clinical-outcomes
February 28, 2018 - This large multistate study used the Institute for Healthcare Improvement's global trigger tool to … Developing and implementing a standardized process for Global Trigger Tool application across a large … August 3, 2016
Intended and unintended effects of large-scale adverse event disclosure … : a controlled before-after analysis of five large-scale notifications.
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psnet.ahrq.gov/node/47284/psn-pdf
December 05, 2018 - Preventable anesthesia-related adverse events at a large
tertiary care center: a nine-year retrospective … Preventable Anesthesia-Related Adverse Events at a Large
Tertiary Care Center: A Nine-Year Retrospective … https://psnet.ahrq.gov/issue/preventable-anesthesia-related-adverse-events-large-tertiary-care-center-nine … https://psnet.ahrq.gov/issue/preventable-anesthesia-related-adverse-events-large-tertiary-care-center-nine-year … https://psnet.ahrq.gov/issue/preventable-anesthesia-related-adverse-events-large-tertiary-care-center-nine-year
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psnet.ahrq.gov/node/43122/psn-pdf
April 08, 2018 - Missed diagnosis of stroke in the emergency department:
a cross-sectional analysis of a large population-based … Missed diagnosis of stroke in the emergency department: a
cross-sectional analysis of a large population-based … https://psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-
large-population-based … https://psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based … https://psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based