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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/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/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/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/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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psnet.ahrq.gov/node/49700/psn-pdf
February 01, 2014 - survived the initial arrest, she remained hypotensive and unfortunately did
not regain any meaningful neurological
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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/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/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
January 01, 2024 - – The score relies on evaluation of 4 organ systems—respiratory, cardiovascular, coagulation,
and neurological—with … INR > 1.3
D-dimer < 2 mg/L FEU D-dimer > 2 mg/L FEU
Fibrinogen > 100 mg/dL Fibrinogen < 100 mg/dL
Neurological
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psnet.ahrq.gov/node/865467/psn-pdf
March 27, 2024 - this case, a seriously ill, encephalopathic patient with active cardiac, respiratory, urological and
neurological
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psnet.ahrq.gov/node/49589/psn-pdf
August 01, 2009 - Hiding in Plain Sight
August 1, 2009
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/hiding-plain-sight
The Case
A 65-year-old woman presented to an emergency department (ED) with 48 hours of nontraumatic left lower
back pain and general malaise. She was diagnosed with a …
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psnet.ahrq.gov/web-mm/comanagement-whos-charge
July 01, 2011 - Comanagement: Who's in Charge?
Citation Text:
Cheng HQ. Comanagement: Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - Misplaced Nasogastric Tube Resulting in Aspiration
Citation Text:
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/primer/telehealth-and-patient-safety
July 27, 2022 - Telehealth and Patient Safety.
Citation Text:
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/33723/psn-pdf
December 01, 2011 - found in hospital
patients including delirium, agitation or confusion, postural hypotension, syncope, neurological
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psnet.ahrq.gov/web-mm/failure-latch
November 27, 2012 - ; and (iii) physical factors of the infant or mother that interfere with milk transfer (anatomical, neurological
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psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
February 01, 2012 - Afterward, the patient displayed worsening neurological status and a CT scan revealed diffuse brain edema
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - He developed worsening neurological status, required mechanical ventilation for airway protection, and