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2841. Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis. | PSNet
      psnet.ahrq.gov/issue/association-intraoperative-anaesthesia-handovers-patient-morbidity-and-mortality-systematic
      June 22, 2022 - Review Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis. Citation Text: Boet S, Djokhdem H, Leir SA, et al. Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systemati…

2842. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.104_slideshow.ppt
      September 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case September 2005 Double Trouble Source and Credits This presentation is based on the Sept. 2005 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Jerry H. Gurwitz, MD, University of…

2843. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33563/psn-pdf
      September 16, 2024 - Culture of Safety September 16, 2024 Culture of Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/culture-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in …

2844. Patient Engagement and Safety | PSNet
      psnet.ahrq.gov/primer/patient-engagement-and-safety
      August 30, 2023 - Patient Engagement and Safety Citation Text: Patient Engagement and Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

2845. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33850/psn-pdf
      January 01, 2018 - EHR Copy and Paste and Patient Safety January 1, 2018 Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety Perspective Although the ability to copy and paste text is a central benefit of computing in general, and electronic…

2846. Selection Criteria and Honorarium Information | PSNet
      psnet.ahrq.gov/Webmm/submit-case-info
      August 10, 2025 - Selection Criteria and Honorarium Information How it works Health care professionals may submit de-identified cases that highlight medical errors or other patient safety/quality issues. Note that you can choose to submit cases either …

2847. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33593/psn-pdf
      June 15, 2024 - Measurement of Patient Safety June 15, 2024 Measurement of Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/measurement-patient-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient …

2848. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837658/psn-pdf
      July 08, 2022 - Preventable Transfer to the Hospital July 8, 2022 Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/preventable-transfer-hospital The Case A 78-year-old veteran with dementia-associated aggressive behavior and multiple comorbidities had…

2849. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49576/psn-pdf
      January 01, 2009 - To Transfer or Not to Transfer January 1, 2009 Pines JM. To Transfer or Not to Transfer. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/transfer-or-not-transfer Case Objectives Explore the benefits of the continuity of hospital care. Understand the rules and regulations behind triage and hospital choice de…

2850. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49691/psn-pdf
      September 01, 2013 - DRESSed for Failure September 1, 2013 Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dressed-failure The Case A 60-year-old woman who uses a wheelchair presented to the emergency department (ED) with right hand cellulitis and an uncomplicated urinary tract infec…

2851. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49604/psn-pdf
      June 01, 2010 - Tacit Handover, Overt Mishap June 1, 2010 Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap The Case A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdo…

2852. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861881/psn-pdf
      January 31, 2024 - In Conversation with...Richard Ricciardi about Office- Based Patient Safety January 31, 2024 Ricciardi R, Lee M, Mossburg S. In Conversation with..Richard Ricciardi about Office-Based Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-pa…

2853. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60172/psn-pdf
      March 01, 2021 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart Originally published on June 12, 2020 Last updated on January 11, 2021 https://psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly- reduc…

2854. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74866/psn-pdf
      February 23, 2022 - Eliminating explicit and implicit biases in health care: evidence and research needs. February 23, 2022 Vela MB, Erondu AI, Smith NA, et al. Eliminating explicit and implicit biases in health care: evidence and research needs. Annu Rev Public Health. 2022;43(1):477-501. doi:10.1146/annurev-publhealth-052620- 10352…

2855. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837797/psn-pdf
      August 10, 2022 - Toward constructive change after making a medical error: recovery from situations of error theory as a psychosocial model for clinician recovery. August 10, 2022 Harrison R, Johnson J, Mcmullan RD, et al. Toward constructive change after making a medical error: recovery from situations of error theory as a psychos…

2856. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836923/psn-pdf
      April 13, 2022 - An e-Delphi study to obtain expert consensus on the level of risk associated with preventable e-prescribing events. April 13, 2022 Heed J, Klein S, Slee A, et al. An e?Delphi study to obtain expert consensus on the level of risk associated with preventable e?prescribing events. Br J Clin Pharmacol. 2022;88(7):3351-…

2857. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40880/psn-pdf
      December 21, 2014 - Relationship between Leapfrog Safe Practices Survey and outcomes in trauma. December 21, 2014 Glance LG, Dick AW, Osler T, et al. Relationship between Leapfrog Safe Practices Survey and outcomes in trauma. Arch Surg. 2011;146(10):1170-7. doi:10.1001/archsurg.2011.247. https://psnet.ahrq.gov/issue/relationship-betw…

2858. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836921/psn-pdf
      April 13, 2022 - Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes. April 13, 2022 Giardina TD, Choi DT, Upadhyay DK, et al. Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes. J Am Med Inform Assoc. 2022;29(6):1091-11…

2859. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836724/psn-pdf
      March 09, 2022 - When no news is bad news: improving diagnostic testing communication through patient engagement. March 9, 2022 Zomerlei T, Carraher A, Chao A, et al. When no news is bad news: improving diagnostic testing communication through patient engagement. J Patient Saf Risk Manage. 2021;26(5):221-224. doi:10.1177/251604352…

2860. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37346/psn-pdf
      March 28, 2012 - Medication administration discrepancies persist despite electronic ordering. March 28, 2012 FitzHenry F, Peterson JF, Arrieta M, et al. Medication Administration Discrepancies Persist Despite Electronic Ordering. J Am Med Inform Assoc. 2007;14(6):756-764. doi:10.1197/jamia.m2359. https://psnet.ahrq.gov/issue/medic…