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8141. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48009/psn-pdf
      May 15, 2019 - Associations between in-hospital mortality, health care utilization, and inpatient costs with the 2011 resident duty hour revision. May 15, 2019 Eid SM, Ponor L, Reed DA, et al. Associations Between In-Hospital Mortality, Health Care Utilization, and Inpatient Costs With the 2011 Resident Duty Hour Revision. J Gra…

8142. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36342/psn-pdf
      March 02, 2011 - Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. March 2, 2011 Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006;145(7):488-496. https://psnet.ahrq.gov/issue/missed…

8143. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44709/psn-pdf
      November 18, 2016 - Lost information during the handover of critically injured trauma patients: a mixed-methods study. November 18, 2016 Zakrison TL, Rosenbloom B, McFarlan A, et al. Lost information during the handover of critically injured trauma patients: a mixed-methods study. BMJ Qual Saf. 2016;25(12):929-936. doi:10.1136/bmjqs-2…

8144. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41557/psn-pdf
      August 01, 2012 - Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients. August 1, 2012 Brenner S, Detz A, Lopez A, et al. Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients. BMJ Qual Saf. 2012;21(8):670-5. doi:1…

8145. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45310/psn-pdf
      January 03, 2017 - Minding the gaps: assessing communication outcomes of electronic preconsultation exchange. January 3, 2017 Price EL, Sewell JL, Chen AH, et al. Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange. Jt Comm J Qual Patient Saf. 2016;42(8):341-54. https://psnet.ahrq.gov/issue/mind…

8146. Medication Handling and Compounding Errors in the Operating Room. | PSNet
      psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
      May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room. Citation Text: Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…

8147. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers | PSNet
      psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
      January 07, 2022 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers Citation Text: Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

8148. In Conversation With... Jeffrey Shuren, MD, JD | PSNet
      psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
      May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD May 28, 2020  Also Read the Essay Citation Text: In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020.In Conversation With... Jeffrey Shuren, MD, JD. PSNet [internet]. Rockville (MD): Agency for Healt…

8149. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849661/psn-pdf
      June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery June 28, 2023 Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023. https://psnet.ahrq.gov/web…

8150. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49849/psn-pdf
      January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep January 1, 2019 Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep Case Objectives List the patient safety events that are unique to in…

8151. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846126/psn-pdf
      March 09, 2023 - Medication Handling and Compounding Errors in the Operating Room. March 15, 2023 Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room The Case A 62-y…

8152. The Role of the FDA in Ensuring Device Safety | PSNet
      psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
      May 28, 2020 - The Role of the FDA in Ensuring Device Safety May 28, 2020  Also Read the Conversation View more articles from the same authors. Citation Text: Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. Rockville (MD): Agency f…

8153. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33856/psn-pdf
      April 01, 2018 - Patient Safety During Hospital Discharge April 1, 2018 Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge Perspective Patients are admitted to the hospital in the United States 35 million times per year.(1)…

8154. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60746/psn-pdf
      July 29, 2020 - Misdiagnosis of a Pelvic Mass versus Pregnancy July 29, 2020 Leiserowitz GS, Herding H. Misdiagnosis of a Pelvic Mass versus Pregnancy. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy The Case A 28-year-old woman arrived at the Emergency Department (ED) complaining o…

8155. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49575/psn-pdf
      November 01, 2008 - Sick and Pregnant November 1, 2008 El-Ibiary S. Sick and Pregnant. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/sick-and-pregnant The Case A 35-year-old woman with chronic asthma presented to the emergency department (ED) with difficulty breathing. The patient informed the staff that she was 17 weeks pre…

8156. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
      January 01, 2020 - Spotlight Spotlight Discharged with IV antibiotics: When issues arise, who manages the complications? Source and Credits • This presentation is based on the February 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Monica Donnel…

8157. Wrong Route for Nutrients | PSNet
      psnet.ahrq.gov/web-mm/wrong-route-nutrients
      September 04, 2010 - Wrong Route for Nutrients Citation Text: Scott-Cawiezell JR. Wrong Route for Nutrients. 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 XML Endno…

8158. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49847/psn-pdf
      November 01, 2018 - Written Signout: It Only Works If You Use The Right One November 1, 2018 Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one The Case A 75-year-old man was hospitalized due to a stro…

8159. Improving Patient Safety and Team Communication through Daily Huddles | PSNet
      psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
      December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles Citation Text: Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citatio…

8160. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42395/psn-pdf
      July 31, 2013 - Return on investment for vendor computerized physician order entry in four community hospitals: the importance of decision support. July 31, 2013 Zimlichman E, Keohane C, Franz C, et al. Return on investment for vendor computerized physician order entry in four community hospitals: the importance of decision suppo…