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1821. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848086/psn-pdf
      April 26, 2023 - Preventable harm in the Canadian organ donation and transplantation system: a descriptive study of missed organ donor identification and referral. April 26, 2023 Zavalkoff S, O’Donnell S, Lalani J, et al. Preventable harm in the Canadian organ donation and transplantation system: a descriptive study of missed orga…

1822. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43523/psn-pdf
      October 29, 2014 - Potentially inappropriate prescribing in older patients discharged from acute care hospitals to residential aged care facilities. October 29, 2014 Poudel A, Peel NM, Nissen L, et al. Potentially inappropriate prescribing in older patients discharged from acute care hospitals to residential aged care facilities. An…

1823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39645/psn-pdf
      August 03, 2010 - Monitoring and reducing central line-associated bloodstream infections: a national survey of state hospital associations. August 3, 2010 Murphy DJ, Needham DM, Goeschel CA, et al. Monitoring and reducing central line-associated bloodstream infections: a national survey of state hospital associations. Am J Med Qual…

1824. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50555/psn-pdf
      October 16, 2019 - Improving critical incident reporting in primary care through education and involvement. October 16, 2019 Müller BS, Beyer M, Blazejewski T, et al. Improving critical incident reporting in primary care through education and involvement. BMJ Open Qual. 2019;8(3):e000556. doi:10.1136/bmjoq-2018-000556. https://psnet…

1825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44120/psn-pdf
      November 06, 2015 - Designing highly reliable adverse-event detection systems to predict subsequent claims. November 6, 2015 Helmchen LA, Burke ME, Wojtusiak J. Designing highly reliable adverse-event detection systems to predict subsequent claims. J Healthc Risk Manag. 2015;34(4):7-17. doi:10.1002/jhrm.21167. https://psnet.ahrq.gov/…

1826. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866168/psn-pdf
      January 02, 2000 - Missed diagnoses of acute cardiac ischemia in the emergency department. January 2, 2000 Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342(16):1163-1170. doi:10.1056/nejm200004203421603. https://psnet.ahrq.gov/issue/missed-diag…

1827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46045/psn-pdf
      December 22, 2018 - Validating domains of patient contextual factors essential to preventing contextual errors: a qualitative study conducted at Chicago area Veterans Health Administration sites. December 22, 2018 Binns-Calvey AE, Malhiot A, Kostovich CT, et al. Validating Domains of Patient Contextual Factors Essential to Preventin…

1828. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863760/psn-pdf
      March 06, 2024 - Imagining improved interactions: patients' designs to address implicit bias. March 6, 2024 Yang C, Coney L, Mohanraj D, et al. AMIA Annu Symp Proc. 2023;2023:774-783. https://psnet.ahrq.gov/issue/imagining-improved-interactions-patients-designs-address-implicit-bias Implicit biases can compromise decision making a…

1829. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44811/psn-pdf
      March 15, 2016 - Prevalence and patterns of potentially avoidable hospitalizations in the US long-term care setting. March 15, 2016 Mcandrew RM, Grabowski DC, Dangi A, et al. Prevalence and patterns of potentially avoidable hospitalizations in the US long-term care setting. Int J Qual Health Care. 2016;28(1):104-9. doi:10.1093/int…

1830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44356/psn-pdf
      October 03, 2017 - Breaking the silence of the switch—increasing transparency about trainee participation in surgery. October 3, 2017 McAlister C. Breaking the Silence of the Switch--Increasing Transparency about Trainee Participation in Surgery. N Engl J Med. 2015;372(26):2477-9. doi:10.1056/NEJMp1502901. https://psnet.ahrq.gov/iss…

1831. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72625/psn-pdf
      January 13, 2021 - US clinicians' experiences and perspectives on resource limitation and patient care during the COVID-19 pandemic. January 13, 2021 Butler CR, Wong SPY, Wightman AG, et al. US clinicians' experiences and perspectives on resource limitation and patient care during the COVID-19 pandemic. JAMA Netw Open. 2020;3(11):e20…

1832. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46544/psn-pdf
      September 12, 2018 - Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review. September 12, 2018 Whitehead NS, Williams L, Meleth S, et al. Interventions to Improve Follow-Up of Laboratory Test Results Pending at Discharge: A Systematic Review. J Hosp Med. 2018. doi:10.12788/jhm.2944. ht…

1833. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46412/psn-pdf
      October 11, 2017 - Team-based care: the changing face of cardiothoracic surgery. October 11, 2017 Crawford TC, Conte J, Sanchez JA. Team-Based Care: The Changing Face of Cardiothoracic Surgery. Surg Clin North Am. 2017;97(4):801-810. doi:10.1016/j.suc.2017.03.003. https://psnet.ahrq.gov/issue/team-based-care-changing-face-cardiothor…

1834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44361/psn-pdf
      November 20, 2015 - Communication in healthcare: a narrative review of the literature and practical recommendations. November 20, 2015 Vermeir P, Vandijck D, Degroote S, et al. Communication in healthcare: a narrative review of the literature and practical recommendations. Int J Clin Pract. 2015;69(11):1257-67. doi:10.1111/ijcp.12686.…

1835. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42992/psn-pdf
      July 03, 2014 - Adverse drug event nonrecognition in emergency departments: an exploratory study on factors related to patients and drugs. July 3, 2014 Roulet L, Ballereau F, Hardouin J-B, et al. Adverse drug event nonrecognition in emergency departments: an exploratory study on factors related to patients and drugs. J Emerg Med.…

1836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49872/psn-pdf
      August 08, 2019 - Spinal Epidural Abscess August 8, 2019 Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess The Case A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a few days of progressive low back pain. She…

1837. Missing the Point—Eye Injury | PSNet
      psnet.ahrq.gov/web-mm/missing-point-eye-injury
      March 01, 2005 - Missing the Point—Eye Injury Citation Text: Sharma R, Brunette DD. Missing the Point—Eye Injury. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

1838. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846127/psn-pdf
      March 15, 2023 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists March 15, 2023 Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among- spec…

1839. Inpatient Transitions of Care: Challenges and Safety Practices | PSNet
      psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
      June 15, 2024 - Inpatient Transitions of Care: Challenges and Safety Practices Citation Text: Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation …

1840. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44166/psn-pdf
      October 13, 2015 - Development and validation of electronic health record–based triggers to detect delays in follow-up of abnormal lung imaging findings. October 13, 2015 Murphy DR, Thomas EJ, Meyer AND, et al. Development and Validation of Electronic Health Record-based Triggers to Detect Delays in Follow-up of Abnormal Lung Imagin…