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3941. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35486/psn-pdf
      December 06, 2011 - The poor state of health care quality in the U.S.: is malpractice liability part of the problem or part of the solution? December 6, 2011 Hyman DA, Silver C. The poor state of health care quality in the U.S.: is malpractice liability part of the problem or part of the solution? Cornell Law Rev. 2005;90(4):893-993.…

3942. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38722/psn-pdf
      June 24, 2009 - Why do people sue doctors? A study of patients and relatives taking legal action. June 24, 2009 Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet. 1994;343(8913):1609-1613. https://psnet.ahrq.gov/issue/why-do-people-sue-doctors-study-patients-a…

3943. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35032/psn-pdf
      February 03, 2011 - Five years after 'To Err is Human': what have we learned? February 3, 2011 Leape L, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005;293(19):2384-90. https://psnet.ahrq.gov/issue/five-years-after-err-human-what-have-we-learned Two of the leaders in the patient safety movement, Lucian …

3944. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40513/psn-pdf
      June 08, 2011 - "Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions. June 8, 2011 Vashi A, Rhodes K. "Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions. Ann Emerg Med. 2011;57(4):315-322.e1. doi:10…

3945. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44580/psn-pdf
      January 13, 2016 - Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors. January 13, 2016 Brigham and Women's Hospital, Harvard Medical School, Partners HealthCare. Silver Spring, MD: US Food and Drug Administration; December 15, 2015. https://psnet.ahrq.gov/issue/computeriz…

3946. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49800/psn-pdf
      July 01, 2017 - The Hidden Harms of Hand Sanitizer July 1, 2017 Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer The Case A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital for community-acquired pn…

3947. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
      October 01, 2008 - Spotlight Case July 2008 Spotlight Case Recurrent Hypoglycemia: A Care Transition Failure? * * Source and Credits This presentation is based on the October 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Ted Eytan, MD, MS, MPH Editor, …

3948. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49499/psn-pdf
      December 02, 2020 - An Outpatient 'Zebra' January 1, 2006 Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/outpatient-zebra The Case A 64-year-old man presented to the outpatient clinic with a chief complaint of left foot pain and numbness. His past medical history included lumbar disc diseas…

3949. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.293_slideshow.ppt
      March 01, 2013 - Spotlight Case July 2008 Spotlight Case A Weighty Mistake * * Source and Credits This presentation is based on the March 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Seth J. Bokser, MD, MPH, Associate Professor of Pediatrics & Medical…

3950. Dependence vs. Pain | PSNet
      psnet.ahrq.gov/web-mm/dependence-vs-pain
      October 30, 2019 - SPOTLIGHT CASE Dependence vs. Pain Citation Text: Gordon AJ. Dependence vs. Pain . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…

3951. Missed Opportunities for Suicide Risk Assessment | PSNet
      psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
      September 27, 2023 - SPOTLIGHT CASE Missed Opportunities for Suicide Risk Assessment Citation Text: Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation For…

3952. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49747/psn-pdf
      December 01, 2015 - Harm From Alarm Fatigue December 1, 2015 Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/harm-alarm-fatigue Case Objectives Define alarm fatigue and describe potential errors that can occur due to alarm fatigue. Identify federal and national agencies focusing on …

3953. Residual Anesthesia: Tepid Burn | PSNet
      psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
      February 10, 2010 - Residual Anesthesia: Tepid Burn Citation Text: Kurrek MM, Twersky RS. Residual Anesthesia: Tepid Burn. 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 EndN…

3954. The surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) study. | PSNet
      psnet.ahrq.gov/issue/surgeon-second-victim-results-boston-intraoperative-adverse-events-surgeons-attitude-bisa
      January 23, 2017 - Study The surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) study. Citation Text: Han K, Bohnen JD, Peponis T, et al. The surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) …

3955. The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception towards Co-Design. | PSNet
      psnet.ahrq.gov/issue/patients-role-diagnostic-safety-and-excellence-passive-reception-towards-co-design
      April 10, 2019 - Book/Report The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception towards Co-Design. Citation Text: Epstein HM, Haskell H, Hemmelgarn C, et al. The Patient’s Role In Diagnostic Safety And Excellence: From Passive Reception Towards Co-Design. Rockville, MD: Agency…

3956. Safety Is Personal: Partnering With Patients and Families for the Safest Care. | PSNet
      psnet.ahrq.gov/issue/safety-personal-partnering-patients-and-families-safest-care
      January 06, 2015 - Book/Report Safety Is Personal: Partnering With Patients and Families for the Safest Care. Citation Text: Safety Is Personal: Partnering With Patients and Families for the Safest Care. NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Boston, MA: National P…

3957. Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals. | PSNet
      psnet.ahrq.gov/issue/overcoming-barriers-adopting-and-implementing-computerized-physician-order-entry-systems-us
      July 10, 2008 - Study Classic Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals. Citation Text: Poon EG, Blumenthal D, Jaggi T, et al. Overcoming barriers to adopting and implementing computerized physician order ent…

3958. Reducing Avoidable Readmissions Effectively campaign: a statewide collaborative. | PSNet
      psnet.ahrq.gov/issue/reducing-avoidable-readmissions-effectively-rare-campaign
      January 31, 2018 - Award Recipient Reducing Avoidable Readmissions Effectively campaign: a statewide collaborative. Citation Text: McCoy KA, Bear-Pfaffendorf K, Foreman JK, et al. Reducing Avoidable Hospital Readmissions Effectively: A Statewide Campaign. Joint Comm J Qual Patient Saf. 2016;40(5):198-204,…

3959. Five years after 'To Err is Human': what have we learned? | PSNet
      psnet.ahrq.gov/issue/five-years-after-err-human-what-have-we-learned
      March 18, 2019 - Commentary Classic Five years after 'To Err is Human': what have we learned? Citation Text: Leape L, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005;293(19):2384-90. Copy Citation Format: Google Scholar PubMed BibTe…

3960. A patient reported approach to identify medical errors and improve patient safety in the emergency department. | PSNet
      psnet.ahrq.gov/issue/patient-reported-approach-identify-medical-errors-and-improve-patient-safety-emergency
      July 13, 2010 - Study A patient reported approach to identify medical errors and improve patient safety in the emergency department. Citation Text: Glickman SW, Mehrotra A, Shea CM, et al. A Patient Reported Approach to Identify Medical Errors and Improve Patient Safety in the Emergency Department. J Pa…