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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844539/psn-pdf
    February 15, 2023 - Partnering with patients and families living with chronic conditions to coproduce diagnostic safety through OurDX: a previsit online engagement tool. February 15, 2023 Bell SK, Dong ZJ, DesRoches CM, et al. Partnering with patients and families living with chronic conditions to coproduce diagnostic safety through …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43090/psn-pdf
    November 23, 2016 - Safety Is Personal: Partnering With Patients and Families for the Safest Care. November 23, 2016 NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Boston, MA: National Patient Safety Foundation; March 2014. https://psnet.ahrq.gov/issue/safety-personal-partnering-patients-and-families…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46756/psn-pdf
    May 09, 2018 - Using a modified A3 lean framework to identify ways to increase students' reporting of mistreatment behaviors. May 9, 2018 Ross PT, Abdoler E, Flygt LA, et al. Using a Modified A3 Lean Framework to Identify Ways to Increase Students' Reporting of Mistreatment Behaviors. Acad Med. 2018;93(4):606-611. doi:10.1097/AC…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73510/psn-pdf
    July 21, 2021 - Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods. July 21, 2021 Chang T-P, Bery AK, Wang Z, et al. Stroke hospitalization after misdiagnosis of “benign dizziness” is lower in sp…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865875/psn-pdf
    May 15, 2024 - Digital health interventions and patient safety in abdominal surgery: a systematic review and meta- analysis. May 15, 2024 Grygorian A, Montano D, Shojaa M, et al. Digital health interventions and patient safety in abdominal surgery: a systematic review and meta-analysis. JAMA Netw Open. 2024;7(4):e248555. doi:10…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848360/psn-pdf
    May 03, 2023 - Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity. May 3, 2023 Liberman AL, Wang Z, Zhu Y, et al. Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47097/psn-pdf
    June 26, 2018 - Patterns of potential opioid misuse and subsequent adverse outcomes in Medicare, 2008 to 2012. June 26, 2018 Carey CM, Jena AB, Barnett ML. Patterns of Potential Opioid Misuse and Subsequent Adverse Outcomes in Medicare, 2008 to 2012. Ann Intern Med. 2018;168(12):837-845. doi:10.7326/M17-3065. https://psnet.ahrq.g…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867177/psn-pdf
    January 01, 2025 - Experiences with diagnostic delay among underserved racial and ethnic patients: a systematic review of the qualitative literature. November 20, 2024 Faugno E, Galbraith AA, Walsh KE, et al. Experiences with diagnostic delay among underserved racial and ethnic patients: a systematic review of the qualitative litera…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45023/psn-pdf
    April 17, 2018 - Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition. April 17, 2018 Graban M. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781498743259. https://psnet.ahrq.gov/issue/lean-hospitals-improving-quality-patient-safety-and-employee-engagement- third-edition Lean methodology fo…
  10. psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
    September 13, 2023 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 31…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49720/psn-pdf
    December 01, 2014 - A Stroke of Error December 1, 2014 Barrett KM. A Stroke of Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/stroke-error Case Objectives State the key clinical factors to assess in a patient with suspected stroke. Appreciate the relationship between elevated blood pressure and stroke in the acute sett…
  12. psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
    February 19, 2020 - SPOTLIGHT CASE Falling Through the Crack (in the Bedrails) Citation Text: Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation F…
  13. psnet.ahrq.gov/web-mm/poor-prognosis
    March 15, 2016 - SPOTLIGHT CASE Poor Prognosis Citation Text: Lamont EB. Poor Prognosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
  14. 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…
  15. psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
    July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room Citation Text: Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60952/psn-pdf
    September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac Arrest September 30, 2020 Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest Disclosure of Relevant Financial Relationships: As a pr…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49451/psn-pdf
    June 01, 2004 - The Result Stopped Here June 1, 2004 Astion ML. The Result Stopped Here. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/result-stopped-here The Case A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital for continued wound care and intravenous (IV) antib…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33614/psn-pdf
    June 01, 2005 - Interpreting the Patient Safety Literature June 1, 2005 Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature Perspective Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49461/psn-pdf
    September 01, 2004 - Reaction to Dye September 1, 2004 Cohan R. Reaction to Dye. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/reaction-dye The Case A patient was referred to urology after having several episodes of gross hematuria. The urologist thought that the patient might have a renal mass and sent him to radiology for a…
  20. psnet.ahrq.gov/web-mm/wrong-channel
    February 01, 2003 - The Wrong Channel Citation Text: Gosbee JW. The Wrong Channel . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

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