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  1. Spotlight Case (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
    May 01, 2006 - The consulting orthopedist reviewed the x-ray report then briefly examined the patient. … Prior to making an incision, the orthopedist reviewed the x-ray and was shocked to notice that it was … A preoperative verification process to ensure that all studies and records are available, have been reviewed … the last moment when the orthopedist discovered that the presumptive diagnosis was wrong The surgeon reviewed
  2. psnet.ahrq.gov/web-mm/crossed-coverage
    September 01, 2015 - Having not received a verbal signout from the primary intern, the cross-covering intern reviewed the … services, the pharmacist provides a chart note with specific recommendations about dosing, which is then reviewed … nurse noticed that no warfarin order was written, as part of her scope of practice, she should have reviewed … The covering intern should have reviewed the laboratory results prior to ordering the medication. … Take-Home Points When a medication, especially a high-risk one, is not ordered, the chart should be reviewed
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34880/psn-pdf
    April 04, 2005 - cedars-sinai-doctors-cling-pen-and-paper-transition-electronic-medical- records-proves A high-profile misstep in implementing computerized provider order entry is reviewed
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35358/psn-pdf
    March 02, 2011 - https://psnet.ahrq.gov/issue/systematic-review-effects-resident-work-hours-patient-safety The authors reviewed
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36601/psn-pdf
    September 29, 2017 - psnet.ahrq.gov/issue/long-working-hours-safety-and-health-toward-national-research-agenda The authors reviewed
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36708/psn-pdf
    April 21, 2011 - psnet.ahrq.gov/issue/missed-breast-cancers-us-guided-core-needle-biopsy-how-reduce-them The investigators reviewed
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35776/psn-pdf
    March 10, 2011 - /systematic-review-literature-multidisciplinary-rounds-design-information- technology The authors reviewed
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37343/psn-pdf
    December 02, 2008 - https://psnet.ahrq.gov/issue/surgical-confusions-ophthalmology This retrospective study reviewed more
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37181/psn-pdf
    October 06, 2011 - inter-rater-reliability-classification-system-hospital-adverse-drug-event-reports Pharmacists and physicians reviewed
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60848/psn-pdf
    January 01, 2022 - adverse-events-related-accidental-unintentional-ingestions-cough-and-cold- medications This study reviewed
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47902/psn-pdf
    April 24, 2019 - An Annual Perspective reviewed work on improving maternal safety.
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74158/psn-pdf
    December 08, 2021 - The authors reviewed design features of patient safety dashboards from 10 hospitals and discuss the
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836925/psn-pdf
    April 13, 2022 - This study retrospectively reviewed inpatient falls resulting in injury and the strength of the improvement
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854261/psn-pdf
    October 04, 2023 - Using a medical malpractice claims database, researchers in this study reviewed 50 conditions identified
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854990/psn-pdf
    November 01, 2023 - Of 439 charts reviewed, 13% contained at least one AE.
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73664/psn-pdf
    September 01, 2021 - The authors reviewed patient data to identify adverse outcomes (e.g., complications, readmissions, reoperation
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847534/psn-pdf
    April 12, 2023 - of the pandemic, charts for hospitalized adult patients under investigation (PUI) for COVID-19 were reviewed
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72474/psn-pdf
    January 01, 2021 - The researchers reviewed presumed medication errors flagged by a computerized decision support system
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50748/psn-pdf
    December 18, 2019 - Due to insufficient high-quality evidence, no reviewed intervention could be recommended, although some
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50795/psn-pdf
    January 15, 2020 - diagnostic-error-emergency-department-learning-national-patient-safety- incident-report This retrospective study reviewed

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