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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/us-emergency-department-visits-acute-harms-over-counter-cough-and-cold-medications-2017-2019
March 24, 2021 - Study
US emergency department visits for acute harms from over-the-counter cough and cold medications, 2017-2019.
Citation Text:
Mital R, Lovegrove MC, Moro RN, et al. US emergency department visits for acute harms from over-the-counter cough and cold medications, 2017-2019. Pharmacoepid…
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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/checklists-reduce-diagnostic-error-systematic-review-literature-using-human-factors-framework
February 22, 2023 - Review
Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework.
Citation Text:
Al-Khafaji J, Townshend RF, Townsend W, et al. Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework.…
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psnet.ahrq.gov/issue/what-can-we-learn-depth-analysis-human-errors-resulting-diagnostic-errors-emergency
June 08, 2022 - Study
What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.
Citation Text:
Baartmans MC, Hooftman J, Zwaan L, et al. What can we learn from in-depth analysis of human errors resul…
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psnet.ahrq.gov/issue/identification-patient-information-corruption-intensive-care-unit-using-scoring-tool-direct
August 04, 2021 - Study
Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover.
Citation Text:
Pickering BW, Hurley K, Marsh B. Identification of patient information corruption in the intensive care unit: using a scori…
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psnet.ahrq.gov/issue/efficacy-mindful-practice-improving-diagnosis-healthcare-systematic-review-and-evidence
May 05, 2021 - Review
The efficacy of mindful practice in improving diagnosis in healthcare: a systematic review and evidence synthesis.
Citation Text:
Pinnock R, Ritchie D, Gallagher S, et al. The efficacy of mindful practice in improving diagnosis in healthcare: a systematic review and evidence synth…
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psnet.ahrq.gov/issue/assessing-experiences-racism-among-black-and-white-patients-emergency-department
December 14, 2022 - Study
Assessing experiences of racism among Black and White patients in the emergency department.
Citation Text:
Agarwal AK, Sagan C, Gonzales R, et al. Assessing experiences of racism among Black and White patients in the emergency department. J Am Coll Emerg Physicians Open. 2022;3(6):…
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psnet.ahrq.gov/issue/bedside-clinicians-perceptions-contributing-role-diagnostic-errors-acutely-ill-patient
May 26, 2021 - Study
Bedside clinicians' perceptions on the contributing role of diagnostic errors in acutely ill patient presentation: a survey of academic and community practice.
Citation Text:
Huang C, Barwise A, Soleimani J, et al. Bedside clinicians' perceptions on the contributing role of diagnos…
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psnet.ahrq.gov/issue/scoping-review-non-professional-medication-practices-and-medication-safety-outcomes-during
May 12, 2021 - Review
A scoping review of non-professional medication practices and medication safety outcomes during public health emergencies.
Citation Text:
Kelly D, Koay A, Mineva G, et al. A scoping review of non-professional medication practices and medication safety outcomes during public health…
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psnet.ahrq.gov/issue/defining-diagnostic-error-scoping-review-assess-impact-national-academies-report-improving
March 03, 2021 - Review
Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health Care.
Citation Text:
Giardina TD, Hunte H, Hill MA, et al. Defining diagnostic error: a scoping review to assess the impact of the National Academies' r…
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psnet.ahrq.gov/issue/what-contributes-diagnostic-error-or-delay-qualitative-exploration-across-diverse-acute-care
March 16, 2022 - Study
What contributes to diagnostic error or delay? A qualitative exploration across diverse acute care settings in the United States.
Citation Text:
Barwise A, Leppin A, Dong Y, et al. What contributes to diagnostic error or delay? A qualitative exploration across diverse acute care se…
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psnet.ahrq.gov/issue/prevalence-undiagnosed-diabetes-identified-novel-electronic-medical-record-diabetes-screening
January 04, 2021 - Study
Prevalence of undiagnosed diabetes identified by a novel electronic medical record diabetes screening program in an urban emergency department in the US.
Citation Text:
Danielson KK, Rydzon B, Nicosia M, et al. Prevalence of undiagnosed diabetes identified by a novel electronic med…
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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/learning-lawsuits-using-malpractice-claims-data-develop-care-transitions-planning-tools
January 21, 2019 - Study
Learning from lawsuits: using malpractice claims data to develop care transitions planning tools.
Citation Text:
Arbaje AI, Werner NE, Kasda EM, et al. Learning From Lawsuits: Using Malpractice Claims Data to Develop Care Transitions Planning Tools. J Patient Saf. 2020;16(1):52-57.…
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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…
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psnet.ahrq.gov/issue/information-transfer-hospital-discharge-systematic-review
February 21, 2015 - Review
Classic
Information transfer at hospital discharge: a systematic review.
Citation Text:
Kattel S, Manning DM, Erwin PJ, et al. Information transfer at hospital discharge: a systematic review. J Patient Saf. 2020;16(1):e25-e33. doi:10.1097/pts.000000000000…
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psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment
Citation Text:
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citatio…
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psnet.ahrq.gov/node/49636/psn-pdf
October 01, 2011 - Mobility Lost in the ICU
October 1, 2011
Smith J. Mobility Lost in the ICU. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/mobility-lost-icu
Case Objectives
Describe the role of the physical therapist in the hospital and ICU.
Compare the risks from immobility with the benefits gained from a program of ther…
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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…