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2141. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44586/psn-pdf
      June 21, 2016 - 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013. June 21, 2016 Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16- 0006-EF. https://psnet.ahrq.gov/issue/2013-annual-hospital-acquired-condition-rate-and-est…

2142. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40842/psn-pdf
      September 24, 2016 - A systematic review of the psychological literature on interruption and its patient safety implications. September 24, 2016 Li SYW, Magrabi F, Coiera E. A systematic review of the psychological literature on interruption and its patient safety implications. J Am Med Inform Assoc. 2012;19(1):6-12. doi:10.1136/amiajn…

2143. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60178/psn-pdf
      April 01, 2020 - Rate of preventable mortality in hospitalized patients: a systematic review and meta-analysis. April 1, 2020 Rodwin BA, Bilan VP, Merchant NB, et al. Rate of preventable mortality in hospitalized patients: a systematic review and meta-analysis. J Gen Intern Med. 2020;35(7):2099-2106. doi:10.1007/s11606-019- 05592-…

2144. 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…

2145. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867143/psn-pdf
      November 13, 2024 - A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized clinical trial. November 13, 2024 Zubkoff L, Zimolzak AJ, Meyer AND, et al. A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized clinical trial. JAMA Netw Open.…

2146. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39396/psn-pdf
      November 02, 2014 - Unmet Needs: Teaching Physicians to Provide Safe Patient Care. November 2, 2014 Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; March 2010. https://psnet.ahrq.gov/issue/unmet-needs-teaching-physicians-provide-safe-patient-care Medical schools face an urgent need to transform their cur…

2147. In Conversation With... Anna Legreid Dopp, Pharm. D | PSNet
      psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
      June 29, 2020 - When a provider who went into the healing profession in the first place causes the medical error, it leads

2148. In Conversation With… Lawrence Smith, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
      February 01, 2012 - date supports the fact that more supervision improves patient safety and that the lack of supervision leads

2149. Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors | PSNet
      psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
      May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 3, 2021 Innovation…

2150. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851971/psn-pdf
      July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up July 31, 2023 Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restricti…

2151. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73202/psn-pdf
      April 28, 2021 - A Postpartum Woman with an Erroneous SARS-CoV-2 Test April 28, 2021 Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test The Case A full-term pregnant patient was admitted in March 2…

2152. Add-on Case and the Missing Checklist | PSNet
      psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
      September 01, 2012 - Add-on Case and the Missing Checklist Citation Text: Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

2153. Breathe Easy: Safe Tracheostomy Management | PSNet
      psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
      June 07, 2023 - Breathe Easy: Safe Tracheostomy Management Citation Text: Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar Bib…

2154. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49848/psn-pdf
      January 01, 2019 - Inadequate Preanesthetic Evaluation, Airway Trouble November 1, 2018 Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble The Case Case #1: A 34-year-old woman was scheduled for a hysteroscopy under g…

2155. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49806/psn-pdf
      September 01, 2017 - Failed Interpretation of Screening Tool: Delayed Treatment September 1, 2017 Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment The Case An 88-year-old man present…

2156. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49787/psn-pdf
      March 01, 2017 - Diagnosing a Missed Diagnosis March 1, 2017 Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis The Case A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and disorientation. She was taking mod…

2157. A Seasonal Care Transition Failure | PSNet
      psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
      June 01, 2016 - A Seasonal Care Transition Failure Citation Text: Young JQ. A Seasonal Care Transition Failure. 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 X…

2158. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-470
      December 31, 2024 - January 15, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, report…

2159. Spotlight Case (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
      October 01, 2009 - Spotlight Case Spotlight Case Difficult Encounters: A CMO and CNO Respond Source and Credits This presentation is based on the October 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Ernie Ring, MD; Jane Hirsch, RN, MS UCSF Medical Cen…

2160. Translating From Normal to Abnormal | PSNet
      psnet.ahrq.gov/web-mm/translating-normal-abnormal
      October 02, 2019 - concluded that the patient's symptoms were likely benign positional vertigo (a common condition that leads