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4361. Departure From Central Line Ritual | PSNet
      psnet.ahrq.gov/web-mm/departure-central-line-ritual
      October 13, 2018 - Departure From Central Line Ritual Citation Text: Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndN…

4362. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49787/psn-pdf
      March 01, 2017 - Diagnosing a Missed Diagnosis March 1, 2017 Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis The Case A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and disorientation. She was taking mod…

4363. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
      June 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfer Troubles 1 2 Source and Credits This presentation is based on the June 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…

4364. Add-on Case and the Missing Checklist | PSNet
      psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
      September 01, 2012 - Add-on Case and the Missing Checklist Citation Text: Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

4365. Transitions from one electronic health record to another: challenges, pitfalls, and recommendations. | PSNet
      psnet.ahrq.gov/issue/transitions-one-electronic-health-record-another-challenges-pitfalls-and-recommendations
      March 17, 2021 - Review Transitions from one electronic health record to another: challenges, pitfalls, and recommendations. Citation Text: Huang C, Koppel R, McGreevey JD, et al. Transitions from one electronic health record to another: challenges, pitfalls, and recommendations. Appl Clin Inform. 2020;1…

4366. The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong answer to the wrong question. | PSNet
      psnet.ahrq.gov/issue/ahrq-report-diagnostic-errors-emergency-department-wrong-answer-wrong-question
      September 23, 2020 - Commentary The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong answer to the wrong question. Citation Text: Kelen GD, Kaji AH, Schreyer KE, et al. The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong answer to the wrong question. Ann Emerg M…

4367. Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. | PSNet
      psnet.ahrq.gov/issue/systematic-review-and-evaluation-physiological-track-and-trigger-warning-systems-identifying
      July 20, 2022 - Review Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. Citation Text: Gao H, McDonnell A, Harrison DA, et al. Systematic review and evaluation of physiological track and trigger warning systems for identif…

4368. Adverse events after transition from ICU to hospital ward: a multicenter cohort study. | PSNet
      psnet.ahrq.gov/issue/adverse-events-after-transition-icu-hospital-ward-multicenter-cohort-study
      October 13, 2018 - Study Adverse events after transition from ICU to hospital ward: a multicenter cohort study. Citation Text: Sauro KM, Soo A, de Grood C, et al. Adverse Events After Transition From ICU to Hospital Ward: A Multicenter Cohort Study*. Crit Care Med. 2020;48(7):946-953. doi:10.1097/ccm.00000…

4369. Adverse drug event-related admissions to a pediatric emergency unit. | PSNet
      psnet.ahrq.gov/issue/adverse-drug-event-related-admissions-pediatric-emergency-unit
      October 05, 2022 - Study Adverse drug event-related admissions to a pediatric emergency unit. Citation Text: Carvalho IV, Sousa VM de, Visacri MB, et al. Adverse drug event-related admissions to a pediatric emergency unit. Pediatr Emerg Care. 2021;37(4):e152-e158. doi:10.1097/pec.0000000000001582. Copy C…

4370. The Ask Me to Explain campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department. | PSNet
      psnet.ahrq.gov/issue/ask-me-explain-campaign-90-day-intervention-promote-patient-and-family-involvement-care
      November 16, 2022 - Study The Ask Me to Explain campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department. Citation Text: Tothy AS, Limper HM, Driscoll J, et al. The Ask Me to Explain Campaign: A 90-Day Intervention to Promote Patient and Family In…

4371. Early warning scores to predict noncritical events overnight in hospitalized medical patients: a prospective case cohort study. | PSNet
      psnet.ahrq.gov/issue/early-warning-scores-predict-noncritical-events-overnight-hospitalized-medical-patients
      March 30, 2022 - Study Early warning scores to predict noncritical events overnight in hospitalized medical patients: a prospective case cohort study. Citation Text: Bittman J, Nijjar AP, Tam P, et al. Early warning scores to predict noncritical events overnight in hospitalized medical patients: a prospe…

4372. Patient safety in chiropractic teaching programs: a mixed methods study. | PSNet
      psnet.ahrq.gov/issue/patient-safety-chiropractic-teaching-programs-mixed-methods-study
      November 04, 2020 - Study Patient safety in chiropractic teaching programs: a mixed methods study. Citation Text: Pohlman KA, Salsbury SA, Funabashi M, et al. Patient safety in chiropractic teaching programs: a mixed methods study. Chiropr Man Therap. 2020;28(1):50. doi:10.1186/s12998-020-00339-0. Copy Ci…

4373. Changes made to orders placed by overnight admitting residents on teaching rounds the next day. | PSNet
      psnet.ahrq.gov/issue/changes-made-orders-placed-overnight-admitting-residents-teaching-rounds-next-day
      July 07, 2021 - Study Changes made to orders placed by overnight admitting residents on teaching rounds the next day. Citation Text: Chiel L, Freiman E, Yarahuan J, et al. Changes made to orders placed by overnight admitting residents on teaching rounds the next day. Hosp Pediatr. 2021;12(1):e35-e38. do…

4374. Do physicians clean their hands? Insights from a covert observational study. | PSNet
      psnet.ahrq.gov/issue/do-physicians-clean-their-hands-insights-covert-observational-study
      July 02, 2019 - Study Do physicians clean their hands? Insights from a covert observational study. Citation Text: Kovacs-Litman A, Wong K, Shojania KG, et al. Do physicians clean their hands? Insights from a covert observational study. J Hosp Med. 2016;11(12):862-864. doi:10.1002/jhm.2632. Copy Citati…

4375. Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions. | PSNet
      psnet.ahrq.gov/issue/look-alike-medications-perioperative-setting-scoping-review-medication-incidents-and-risk
      October 04, 2023 - Review Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions. Citation Text: Ryan AN, Robertson KL, Glass BD. Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduct…

4376. The disclosure dilemma—large-scale adverse events. | PSNet
      psnet.ahrq.gov/issue/disclosure-dilemma-large-scale-adverse-events
      January 22, 2017 - Commentary The disclosure dilemma—large-scale adverse events. Citation Text: Dudzinski DM, Hébert PC, Foglia MB, et al. The disclosure dilemma--large-scale adverse events. New Engl J Med. 2010;363(10):978-986. doi:10.1056/NEJMhle1003134. Copy Citation Format: DOI Google S…

4377. The accuracy of preliminary diagnoses made by paramedics - a cross-sectional comparative study. | PSNet
      psnet.ahrq.gov/issue/accuracy-preliminary-diagnoses-made-paramedics-cross-sectional-comparative-study
      September 16, 2020 - Study The accuracy of preliminary diagnoses made by paramedics - a cross-sectional comparative study. Citation Text: Koivulahti O, Tommila M, Haavisto E. The accuracy of preliminary diagnoses made by paramedics – a cross-sectional comparative study. Scand J Trauma Resusc Emerg Med. 2020;…

4378. Exploring system features of primary care practices that promote better providers' clinical work satisfaction: a qualitative comparative analysis. | PSNet
      psnet.ahrq.gov/issue/exploring-system-features-primary-care-practices-promote-better-providers-clinical-work
      May 25, 2022 - Study Exploring system features of primary care practices that promote better providers' clinical work satisfaction: a qualitative comparative analysis. Citation Text: Liu L, Chien AT, Singer SJ. Exploring system features of primary care practices that promote better providers’ clinical …

4379. Social disparities in patient safety in primary care: a systematic review. | PSNet
      psnet.ahrq.gov/issue/social-disparities-patient-safety-primary-care-systematic-review
      January 08, 2025 - Review Emerging Classic Social disparities in patient safety in primary care: a systematic review. Citation Text: Piccardi C, Detollenaere J, Bussche PV, et al. Social disparities in patient safety in primary care: a systematic review. Int J Equity Health. 2018;…

4380. Why and how to approach user experience in safety-critical domains: the example of health care. | PSNet
      psnet.ahrq.gov/issue/why-and-how-approach-user-experience-safety-critical-domains-example-health-care
      May 05, 2021 - Commentary Why and how to approach user experience in safety-critical domains: the example of health care. Citation Text: Grundgeiger T, Hurtienne J, Happel O. Why and how to approach user experience in safety-critical domains: the example of health care. Hum Factors. 2020;63(5):821-832.…