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psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - Hospital Boston Director, Sleep and Patient Safety Program, Sleep Medicine,
Departments of Medicine and Neurology
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psnet.ahrq.gov/node/33723/psn-pdf
December 01, 2011 - 1000 bed-days (2,3), with much higher rates reported from areas such as
geriatric, psychogeriatric, neurology
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - 1000 bed-days ( 2,3 ), with much higher rates reported from areas such as geriatric, psychogeriatric, neurology
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psnet.ahrq.gov/issue/impact-weekend-effect-postoperative-mortality-patients-undergoing-emergency-general-surgery
December 04, 2016 - Review
Impact of weekend effect on postoperative mortality in patients undergoing emergency General surgery procedures: meta-analysis of prospectively maintained national databases across the world.
Citation Text:
Hajibandeh S, Hajibandeh S, Satyadas T. Impact of weekend effect on postop…
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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/clinical-impact-intraoperative-electronic-health-record-downtime-surgical-patients
March 14, 2016 - Study
Clinical impact of intraoperative electronic health record downtime on surgical patients.
Citation Text:
Harrison AM, Siwani R, Pickering BW, et al. Clinical impact of intraoperative electronic health record downtime on surgical patients. J Am Med Inform Assoc. 2019;26(10):928-933.…
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - Hospital Boston Director, Sleep and Patient Safety Program, Sleep Medicine, Departments of Medicine and Neurology
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psnet.ahrq.gov/issue/antecedent-treat-and-release-diagnoses-prior-sepsis-hospitalization-among-adult-emergency
May 12, 2021 - Study
Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology.
Citation Text:
Nassery N, Horberg MA, …
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psnet.ahrq.gov/issue/feasibility-patient-reported-diagnostic-errors-following-emergency-department-discharge-pilot
August 19, 2020 - Study
Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study.
Citation Text:
Gleason KT, Peterson SM, Dennison Himmelfarb CR, et al. Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot stud…
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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.
Copy Citation
Format: …
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psnet.ahrq.gov/issue/missed-acute-myocardial-infarction-emergency-department-standardizing-measurement
May 12, 2021 - Study
Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method.
Citation Text:
Sharp AL, Baecker A, Nassery N, et al. Missed acute myocardial infarction in the emergency department–standardizing measurem…
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psnet.ahrq.gov/node/860049/psn-pdf
January 04, 2024 - The
pediatric neurology team was involved in her care starting on the second hospital day.
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psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination
April 29, 2020 - Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination
Citation Text:
Valdes W, Utter GH. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Hea…
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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.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/node/49836/psn-pdf
July 01, 2018 - Primary Workaround, Secondary Complication
July 1, 2018
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
The Case
A young adult with a progressive neurological disorder presented to a hospital emerg…
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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/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…
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psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
January 01, 2024 - Neurology. 1960;10:512-521. [Available at]
Hochman MS, Naidich TP, Kobetz SA, et al. … Neurology. 1992;42(8):1628-1630. [Available at]
Schumacher HW, Wassmann H, Podlinski C.
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psnet.ahrq.gov/node/49807/psn-pdf
October 01, 2017 - In the ED, neurology was consulted and
concluded that the patient's symptoms were likely benign positional
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psnet.ahrq.gov/node/49476/psn-pdf
March 02, 2005 - Around the Block
March 1, 2005
Minichiello T. Around the Block. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/around-block
The Case
A 77-year-old woman with multiple medical problems was admitted to the hospital for an elective knee
replacement. The orthopedic surgeon, recognizing the risk of deep vein th…