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psnet.ahrq.gov/issue/medication-errors-homes-children-chronic-conditions
April 27, 2010 - Study
Medication errors in the homes of children with chronic conditions.
Citation Text:
Walsh KE, Mazor KM, Stille CJ, et al. Medication errors in the homes of children with chronic conditions. Arch Dis Child. 2011;96(6):581-6. doi:10.1136/adc.2010.204479.
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psnet.ahrq.gov/issue/nature-adverse-events-hospitalized-patients-results-harvard-medical-practice-study-ii
February 18, 2011 - Study
Classic
The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II.
Citation Text:
Leape L, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Pra…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - Workup of Delirium
History and physical examination
Neurological examination
Collateral information
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psnet.ahrq.gov/node/49534/psn-pdf
May 01, 2007 - By report, neurological exam revealed
only confusion and diminished deep tendon reflexes.
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - greater than 20 mm differential), new aortic
regurgitation, signs of pericardial tamponade, and focal neurological … murmur 28 21-36
Pulse deficit 31 24-39
Pericardial rub 6 3-13
Congestive heart failure 15 4-33
Focal neurological
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - greater than 20 mm differential), new aortic regurgitation, signs of pericardial tamponade, and focal neurological … Pericardial rub 6 3-13 Congestive heart failure 15 4-33 Focal neurological
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psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based
April 08, 2018 - Study
Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample.
Citation Text:
Newman-Toker DE, Moy E, Valente E, et al. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-b…
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psnet.ahrq.gov/issue/views-practicing-physicians-and-public-medical-errors
August 03, 2009 - Study
Classic
Views of practicing physicians and the public on medical errors.
Citation Text:
Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347(24):1933-40.
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Fo…
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psnet.ahrq.gov/issue/are-autopsy-findings-still-relevant-management-critically-ill-patients-modern-era
April 22, 2015 - Study
Are autopsy findings still relevant to the management of critically ill patients in the modern era?
Citation Text:
Fröhlich S, Ryan O, Murphy N, et al. Are autopsy findings still relevant to the management of critically ill patients in the modern era? Crit Care Med. 2014;42(2):336…
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psnet.ahrq.gov/issue/polypharmacy-and-potentially-inappropriate-medication-people-dementia-nationwide-study
March 06, 2012 - Study
Emerging Classic
Polypharmacy and potentially inappropriate medication in people with dementia: a nationwide study.
Citation Text:
Kristensen RU, Nørgaard A, Jensen-Dahm C, et al. Polypharmacy and Potentially Inappropriate Medication in People with Dementi…
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psnet.ahrq.gov/issue/incidence-never-events-among-weekend-admissions-versus-weekday-admissions-us-hospitals
November 03, 2015 - Study
Classic
Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals: national analysis.
Citation Text:
Attenello FJ, Wen T, Cen SY, et al. Incidence of "never events" among weekend admissions versus weekday admissions to …
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psnet.ahrq.gov/node/33691/psn-pdf
December 01, 2009 - //#ref7
Subsequent studies have looked at the impact of disruptive behaviors in perioperative and neurological
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psnet.ahrq.gov/node/49628/psn-pdf
June 01, 2011 - Routine Goes Awry
June 1, 2011
Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/routine-goes-awry
The Case
A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and
scheduled for a tonsillectomy and adenoidectomy. She was in ot…
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - A neurological exam confirmed that the pupils were equal and reactive, albeit pinpoint.
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psnet.ahrq.gov/node/843736/psn-pdf
February 01, 2023 - She was extubated after nine days in
intensive care and survived without any neurological sequelae.
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psnet.ahrq.gov/innovation/demonstrating-value-standardized-cognitive-assessment-tool-through-use-interprofessional
December 02, 2020 - EMERGING INNOVATIONS
Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds.
Citation Text:
Hayes M, Wheeling D, Kaul-Connolly S. Demonstrating the value of a standardized cognitive assessment tool through the use of interprofes…
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psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis
September 23, 2020 - Study
"SWARMing" to improve patient care: a novel approach to root cause analysis.
Citation Text:
Li J, Boulanger B, Norton J, et al. "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause Analysis. Jt Comm J Qual Patient Saf. 2015;41(11):494-501.
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Format: …
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psnet.ahrq.gov/node/841493/psn-pdf
December 14, 2022 - Telehealth and Patient Safety.
December 14, 2022
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/telehealth-and-patient-safety
Background
In recent years, telehealth, or the delivery of healthcare over a distance using telecommunications
techno…
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psnet.ahrq.gov/web-mm/translating-normal-abnormal
October 02, 2019 - SPOTLIGHT CASE
Translating From Normal to Abnormal
Citation Text:
Turner AM. Translating From Normal to Abnormal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibT…
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - and (iii) physical factors of the infant or mother
that interfere with milk transfer (anatomical, neurological