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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37345/psn-pdf
    May 26, 2011 - Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients. May 26, 2011 Holdsworth MT, Fichtl RE, Raisch DW, et al. Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients. Pediatrics. 2007;120(5):1058-66. htt…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46560/psn-pdf
    January 24, 2019 - The hidden cost of regulation: the administrative cost of reporting serious reportable events. January 24, 2019 Blanchfield BB, Acharya B, Mort E. The Hidden Cost of Regulation: The Administrative Cost of Reporting Serious Reportable Events. Jt Comm J Qual Patient Saf. 2018;44(4):212-218. doi:10.1016/j.jcjq.2017.0…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42154/psn-pdf
    January 07, 2015 - Paper- and computer-based workarounds to electronic health record use at three benchmark institutions. January 7, 2015 Flanagan ME, Saleem JJ, Millitello LG, et al. Paper- and computer-based workarounds to electronic health record use at three benchmark institutions. J Am Med Inform Assoc. 2013;20(e1):e59-66. doi:…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44542/psn-pdf
    December 22, 2018 - The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study. December 22, 2018 Heyland DK, Ilan R, Jiang X, et al. The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observ…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39777/psn-pdf
    November 04, 2012 - The Economic Measurement of Medical Errors. November 4, 2012 Shreve J, van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. Schaumburg, IL: The Society of Actuaries; 2010. https://psnet.ahrq.gov/issue/economic-measurement-medical-errors Although the Institute of Medicine's estimate of up to 98,000 deaths ye…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46435/psn-pdf
    August 20, 2018 - Patients' experiences with communication-and-resolution programs after medical injury. August 20, 2018 Moore J, Bismark M, Mello MM. Patients' Experiences With Communication-and-Resolution Programs After Medical Injury. JAMA Intern Med. 2017;177(11):1595-1603. doi:10.1001/jamainternmed.2017.4002. https://psnet.ahr…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47452/psn-pdf
    December 27, 2018 - The preventable proportion of healthcare-associated infections 2005-2016: systematic review and meta- analysis. December 27, 2018 Schreiber PW, Sax H, Wolfensberger A, et al. The preventable proportion of healthcare-associated infections 2005-2016: Systematic review and meta-analysis. Infect Control Hosp Epidemiol…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45739/psn-pdf
    July 02, 2017 - High-risk medications in hospitalized elderly adults: are we making it easy to do the wrong thing? July 2, 2017 Blachman NL, Leipzig RM, Mazumdar M, et al. High-Risk Medications in Hospitalized Elderly Adults: Are We Making It Easy to Do the Wrong Thing? J Am Geriatr Soc. 2017;65(3):603-607. doi:10.1111/jgs.14703. …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44376/psn-pdf
    October 08, 2016 - Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis. October 8, 2016 Hogan H, Zipfel R, Neuburger J, et al. Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37096/psn-pdf
    June 24, 2010 - Impact of diagnosis-timing indicators on measures of safety, comorbidity, and case mix groupings from administrative data sources. June 24, 2010 Naessens JM, Campbell CR, Berg B, et al. Impact of diagnosis-timing indicators on measures of safety, comorbidity, and case mix groupings from administrative data sources…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45889/psn-pdf
    August 16, 2017 - New persistent opioid use after minor and major surgical procedures in US adults. August 16, 2017 Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504. https://psnet.ahrq.gov/issue…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45333/psn-pdf
    September 21, 2016 - Association of inpatient hospital experience with patient safety indicators: a cross-sectional, Canadian study. September 21, 2016 Kemp KA, Santana MJ, Southern DA, et al. Association of inpatient hospital experience with patient safety indicators: a cross-sectional, Canadian study. BMJ Open. 2016;6(7):e011242. doi…
  13. psnet.ahrq.gov/web-mm/urine-tough-position
    January 01, 2009 - Urine a Tough Position Citation Text: Gandhi TK. Urine a Tough Position. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49631/psn-pdf
    July 01, 2011 - Patient Safety and Adherence to Self-Administered Medications July 1, 2011 Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications The Case A 30-year-o…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49473/psn-pdf
    March 01, 2005 - On O.R. Off? March 1, 2005 Leonard M. On O.R. Off? PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/or The Case An elderly man was admitted to the vascular surgery service with rest pain in his leg. Angiography demonstrated peripheral artery disease with anatomy suitable for revascularization. A consulting …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49449/psn-pdf
    June 01, 2004 - Lethal Vertigo June 1, 2004 Furman JM. Lethal Vertigo. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-vertigo The Case A 64-year-old woman, with no prior medical history, complained of sudden onset of severe vertigo and vomiting, without headache. Her initial blood pressure in the emergency departme…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49487/psn-pdf
    August 21, 2005 - Surprise Wire August 21, 2005 Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/surprise-wire The Case A 39-year-old man with a history of liver disease presented to the emergency department (ED) with gastrointestinal bleeding and altered mental status. Due to his clinic…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49395/psn-pdf
    April 01, 2003 - Medication Overdose April 1, 2003 Kaushal R. Medication Overdose. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/medication-overdose The Case A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He was diagnosed with status epilepticus and started on a loading…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49850/psn-pdf
    January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia January 1, 2019 Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia The Case A 72-year-old woman with a history of severe peripheral vascular dis…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49861/psn-pdf
    May 01, 2019 - Updates in the Management of High-Risk Pulmonary Embolism May 1, 2019 Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism Case Objectives Review common risk factors, typical present…

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