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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/issue/evaluation-feedback-modalities-and-preferences-regarding-feedback-decision-making-pediatric
September 08, 2021 - Study
Evaluation of feedback modalities and preferences regarding feedback on decision-making in a pediatric emergency department.
Citation Text:
Graham JMK, Ambroggio L, Leonard JE, et al. Evaluation of feedback modalities and preferences regarding feedback on decision-making in a pedia…
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psnet.ahrq.gov/issue/symptom-disease-pair-analysis-diagnostic-error-spade-conceptual-framework-and-methodological
October 23, 2019 - Review
Classic
Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data.
Citation Text:
Liberman AL, Newman-Toker DE. Symptom-Disease Pair Analysis of D…
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psnet.ahrq.gov/issue/misdiagnosis-thoracic-aortic-emergencies-occurs-frequently-among-transfers-aortic-referral
October 28, 2020 - Study
Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers to aortic referral centers: an analysis of over 3700 patients.
Citation Text:
Arnaoutakis GJ, Ogami T, Aranda‐Michel E, et al. Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers…
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psnet.ahrq.gov/issue/malpractice-claims-related-diagnostic-errors-hospital
September 16, 2020 - Study
Classic
Malpractice claims related to diagnostic errors in the hospital.
Citation Text:
Gupta A, Snyder A, Kachalia A, et al. Malpractice claims related to diagnostic errors in the hospital. BMJ Qual Saf. 2017;27(1):53-60. doi:10.1136/bmjqs-2017-006774.
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psnet.ahrq.gov/issue/clinicians-insights-emergency-department-boarding-explanatory-mixed-methods-study-evaluating
October 23, 2019 - Study
Clinicians' insights on emergency department boarding: an explanatory mixed methods study evaluating patient care and clinician well-being.
Citation Text:
Loke DE, Green KA, Wessling EG, et al. Clinicians' insights on emergency department boarding: an explanatory mixed methods stud…
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psnet.ahrq.gov/issue/implementation-world-health-organization-trauma-care-checklist-program-11-centers-across
November 16, 2022 - Study
Implementation of the World Health Organization Trauma Care Checklist Program in 11 centers across multiple economic strata: effect on care process measures.
Citation Text:
Lashoher A, Schneider EB, Juillard C, et al. Implementation of the World Health Organization Trauma Care Chec…
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psnet.ahrq.gov/issue/occurrence-no-harm-incidents-and-adverse-events-hospitalized-patients-ischemic-stroke-or-tia
August 05, 2020 - Study
Occurrence of no-harm incidents and adverse events in hospitalized patients with ischemic stroke or TIA: a cohort study using trigger tool methodology.
Citation Text:
Nowak B, Schwendimann R, Lyrer P, et al. Occurrence of no-harm incidents and adverse events in hospitalized patient…
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psnet.ahrq.gov/issue/electronic-diagnostic-support-emergency-physician-triage-qualitative-study-thematic-analysis
October 27, 2021 - Study
Electronic diagnostic support in emergency physician triage: qualitative study with thematic analysis of interviews.
Citation Text:
Sibbald M, Abdulla B, Keuhl A, et al. Electronic diagnostic support in emergency physician triage: qualitative study with thematic analysis of intervi…
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psnet.ahrq.gov/issue/burden-serious-harms-diagnostic-error-usa
June 03, 2020 - Study
Burden of serious harms from diagnostic error in the USA.
Citation Text:
Newman-Toker DE, Nassery N, Schaffer AC, et al. Burden of serious harms from diagnostic error in the USA. BMJ Qual Saf. 2024;33(2):109-120. doi:10.1136/bmjqs-2021-014130.
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psnet.ahrq.gov/issue/opioid-guidelines-common-dental-surgical-procedures-multidisciplinary-panel-consensus
April 28, 2021 - Organizational Policy/Guidelines
Opioid guidelines for common dental surgical procedures: a multidisciplinary panel consensus.
Citation Text:
Farooqi OA, Bruhn WE, Lecholop MK, et al. Opioid guidelines for common dental surgical procedures: a multidisciplinary panel consensus. Int J Oral…
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psnet.ahrq.gov/issue/breakdowns-initial-patient-provider-encounter-are-frequent-source-diagnostic-error-among
January 23, 2019 - Review
Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database.
Citation Text:
Liberman AL, Skillings J, Greenberg P, et al. Breakdowns in the initial patient-provid…
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psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
January 01, 2020 - Spotlight
Spotlight
Inpatient Stroke Management in a Patient
with Type 1 Diabetes and Home Insulin
Pump
Source and Credits
• This presentation is based on the October 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Berit B…
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psnet.ahrq.gov/issue/medication-errors-acute-cardiovascular-and-stroke-patients-scientific-statement-american
February 03, 2011 - Organizational Policy/Guidelines
Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association.
Citation Text:
Michaels AD, Spinler SA, Leeper B, et al. Medication Errors in Acute Cardiovascular and Stroke Patients. Circulatio…
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psnet.ahrq.gov/issue/economic-consequences-medical-injuries-implications-no-fault-insurance-plan
February 18, 2011 - Study
Classic
The economic consequences of medical injuries: implications for a no-fault insurance plan.
Citation Text:
Johnson WG, Brennan TA, Newhouse JP, et al. The economic consequences of medical injuries. Implications for a no-fault insurance plan. JAMA.…
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psnet.ahrq.gov/issue/sign-right-here-and-youre-good-go-content-analysis-audiotaped-emergency-department-discharge
December 18, 2013 - Study
"Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions.
Citation Text:
Vashi A, Rhodes K. "Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions. Ann Emer…
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psnet.ahrq.gov/issue/under-reporting-deaths-coroner-doctors-retrospective-review-deaths-two-hospitals-melbourne
April 24, 2018 - Study
Under-reporting of deaths to the coroner by doctors: a retrospective review of deaths in two hospitals in Melbourne, Australia.
Citation Text:
Charles A, Ranson D, Bohensky M, et al. Under-reporting of deaths to the coroner by doctors: a retrospective review of deaths in two hosp…
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psnet.ahrq.gov/issue/serious-adverse-drug-events-reported-fda-analysis-fda-adverse-event-reporting-system-2006
December 15, 2010 - Study
Serious adverse drug events reported to the FDA: analysis of the FDA Adverse Event Reporting System 2006–2014 database.
Citation Text:
Sonawane KB, Cheng N, Hansen RA. Serious Adverse Drug Events Reported to the FDA: Analysis of the FDA Adverse Event Reporting System 2006-2014 Data…
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psnet.ahrq.gov/issue/workplace-factors-associated-burnout-family-physicians
July 03, 2016 - Study
Workplace factors associated with burnout of family physicians.
Citation Text:
Rassolian M, Peterson LE, Fang B, et al. Workplace Factors Associated With Burnout of Family Physicians. JAMA Intern Med. 2017;177(7):1036-1038. doi:10.1001/jamainternmed.2017.1391.
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psnet.ahrq.gov/issue/learning-preventable-deaths-exploring-case-record-reviewers-narratives-using-change-analysis
June 17, 2014 - Study
Learning from preventable deaths: exploring case record reviewers' narratives using change analysis.
Citation Text:
Hogan H, Healey F, Neale G, et al. Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. J R Soc Med. 2014;107(9):365-7…