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psnet.ahrq.gov/node/35927/psn-pdf
February 17, 2011 - Claims, errors, and compensation payments in medical
malpractice litigation.
February 17, 2011
Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical
malpractice litigation. N Engl J Med. 2006;354(19):2024-33.
https://psnet.ahrq.gov/issue/claims-errors-and-compensation-payme…
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psnet.ahrq.gov/node/44601/psn-pdf
February 23, 2018 - Emergency department visits for adverse events related
to dietary supplements.
February 23, 2018
Geller AI, Shehab N, Weidle NJ, et al. Emergency Department Visits for Adverse Events Related to Dietary
Supplements. N Engl J Med. 2015;373(16):1531-40. doi:10.1056/NEJMsa1504267.
https://psnet.ahrq.gov/issue/emergenc…
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psnet.ahrq.gov/node/44178/psn-pdf
July 03, 2016 - A trigger tool to detect harm in pediatric inpatient
settings.
July 3, 2016
Stockwell DC, Bisarya H, Classen D, et al. A trigger tool to detect harm in pediatric inpatient settings.
Pediatrics. 2015;135(6):1036-42. doi:10.1542/peds.2014-2152.
https://psnet.ahrq.gov/issue/trigger-tool-detect-harm-pediatric-inpatien…
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psnet.ahrq.gov/issue/ismp-medication-safety-alertr-nurse-advise-err
January 26, 2023 - Newsletter/Journal
ISMP Medication Safety Alert!® Nurse-Advise ERR.
Citation Text:
ISMP Medication Safety Alert!® Nurse-Advise ERR. Plymouth Meeting, PA: Institute for Safe Medication Practices.
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psnet.ahrq.gov/node/37945/psn-pdf
July 26, 2010 - A survey of hospital quality improvement activities.
July 26, 2010
Cohen AB, Restuccia JD, Shwartz M, et al. A survey of hospital quality improvement activities. Med Care
Res Rev. 2008;65(5):571-95. doi:10.1177/1077558708318285.
https://psnet.ahrq.gov/issue/survey-hospital-quality-improvement-activities
The Instit…
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psnet.ahrq.gov/node/45509/psn-pdf
September 28, 2016 - Computerized triggers of big data to detect delays in
follow-up of chest imaging results.
September 28, 2016
Murphy DR, Meyer AND, Bhise V, et al. Computerized Triggers of Big Data to Detect Delays in Follow-up
of Chest Imaging Results. Chest. 2016;150(3):613-20. doi:10.1016/j.chest.2016.05.001.
https://psnet.ahrq…
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psnet.ahrq.gov/node/47238/psn-pdf
October 13, 2018 - Evaluating shared decision making for lung cancer
screening.
October 13, 2018
Brenner AT, Malo TL, Margolis M, et al. Evaluating Shared Decision Making for Lung Cancer Screening.
JAMA Intern Med. 2018;178(10):1311-1316. doi:10.1001/jamainternmed.2018.3054.
https://psnet.ahrq.gov/issue/evaluating-shared-decision-ma…
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psnet.ahrq.gov/node/45471/psn-pdf
September 21, 2016 - Vital signs: epidemiology of sepsis: prevalence of health
care factors and opportunities for prevention.
September 21, 2016
Novosad SA, Sapiano MRP, Grigg C, et al. Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care
Factors and Opportunities for Prevention. MMWR Morb Mortal Wkly Rep. 2016;65(33):864-869…
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psnet.ahrq.gov/node/36364/psn-pdf
February 14, 2017 - National surveillance of emergency department visits for
outpatient adverse drug events.
February 14, 2017
Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for
outpatient adverse drug events. JAMA. 2006;296(15):1858-66.
https://psnet.ahrq.gov/issue/national-surveil…
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psnet.ahrq.gov/node/45097/psn-pdf
May 09, 2017 - Changes in prescription and over-the-counter medication
and dietary supplement use among older adults in the
United States, 2005 vs 2011.
May 9, 2017
Qato DM, Wilder J, Schumm P, et al. Changes in Prescription and Over-the-Counter Medication and
Dietary Supplement Use Among Older Adults in the United States, 2005 …
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psnet.ahrq.gov/node/44112/psn-pdf
November 03, 2015 - Unexpected death within 72 hours of emergency
department visit: were those deaths preventable?
November 3, 2015
Goulet H, Guerand V, Bloom B, et al. Unexpected death within 72 hours of emergency department visit:
were those deaths preventable? Crit Care. 2015;19(1):154. doi:10.1186/s13054-015-0877-x.
https://psnet…
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psnet.ahrq.gov/node/39662/psn-pdf
April 30, 2014 - Patient record review of the incidence, consequences,
and causes of diagnostic adverse events.
April 30, 2014
Zwaan L, de Bruijne M, Wagner C, et al. Patient record review of the incidence, consequences, and causes
of diagnostic adverse events. Arch Intern Med. 2010;170(12):1015-21.
doi:10.1001/archinternmed.2010.…
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psnet.ahrq.gov/node/44031/psn-pdf
November 03, 2015 - Diagnostic concordance among pathologists interpreting
breast biopsy specimens.
November 3, 2015
Elmore JG, Longton GM, Carney PA, et al. Diagnostic concordance among pathologists interpreting breast
biopsy specimens. JAMA. 2015;313(11):1122-1132. doi:10.1001/jama.2015.1405.
https://psnet.ahrq.gov/issue/diagnostic…
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psnet.ahrq.gov/node/47671/psn-pdf
January 01, 2019 - Racial, ethnic, and socioeconomic disparities in patient
safety events for hospitalized children.
December 19, 2018
Stockwell DC, Landrigan CP, Toomey SL, et al. Racial, Ethnic, and Socioeconomic Disparities in Patient
Safety Events for Hospitalized Children. Hosp Pediatr. 2019;9(1):1-5. doi:10.1542/hpeds.2018-0131…
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psnet.ahrq.gov/node/42895/psn-pdf
December 18, 2014 - National trends in patient safety for four common
conditions, 2005–2011.
December 18, 2014
Wang Y, Eldridge N, Metersky M, et al. National trends in patient safety for four common conditions, 2005-
2011. N Engl J Med. 2014;370(4):341-51. doi:10.1056/NEJMsa1300991.
https://psnet.ahrq.gov/issue/national-trends-patie…
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psnet.ahrq.gov/node/46404/psn-pdf
December 07, 2017 - Preventable and mitigable adverse events in cancer care:
measuring risk and harm across the continuum.
December 7, 2017
Lipitz-Snyderman A, Pfister D, Classen D, et al. Preventable and mitigable adverse events in cancer care:
measuring risk and harm across the continuum. Cancer. 2017;123(23):4728-4736. doi:10.1002/…
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psnet.ahrq.gov/node/39139/psn-pdf
June 02, 2010 - Assessing resident safety culture in nursing homes:
using the nursing home survey on resident safety.
June 2, 2010
Castle NG, Wagner LM, Perera S, et al. Assessing Resident Safety Culture in Nursing Homes. J Patient
Saf. 2010;64(2):59-67. doi:10.1097/pts.0b013e3181bc05fc.
https://psnet.ahrq.gov/issue/assessing-res…
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psnet.ahrq.gov/node/41455/psn-pdf
June 13, 2012 - Medication errors during medical emergencies in a large,
tertiary care, academic medical center.
June 13, 2012
Gokhman R, Seybert AL, Phrampus P, et al. Medication errors during medical emergencies in a large,
tertiary care, academic medical center. Resuscitation. 2012;83(4):482-7.
doi:10.1016/j.resuscitation.2011…
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psnet.ahrq.gov/node/47602/psn-pdf
January 27, 2019 - Association of nurse workload with missed nursing care
in the neonatal intensive care unit.
January 27, 2019
Tubbs-Cooley HL, Mara CA, Carle AC, et al. Association of Nurse Workload With Missed Nursing Care in
the Neonatal Intensive Care Unit. JAMA Pediatr. 2019;173(1):44-51.
doi:10.1001/jamapediatrics.2018.3619.
…
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psnet.ahrq.gov/node/49533/psn-pdf
March 01, 2007 - Staggered Sensitivity Results
March 1, 2007
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/staggered-sensitivity-results
The Case
A 60-year-old woman with squamous cell carcinoma of the glottis underwent laryngectomy, anterior neck
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