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4101. Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. | PSNet
      psnet.ahrq.gov/issue/using-assessment-reasoning-tool-facilitate-feedback-about-diagnostic-reasoning
      February 23, 2022 - Study Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. Citation Text: Cohen AL, Sur M, Falco C, et al. Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. Diagnosis (Berl). 2022;9(4):476-484. doi:10.1515/dx-20…

4102. Patients' perceptions of using technology for self-reporting cancer medication safety events from home. | PSNet
      psnet.ahrq.gov/issue/patients-perceptions-using-technology-self-reporting-cancer-medication-safety-events-home
      June 05, 2024 - Study Patients' perceptions of using technology for self-reporting cancer medication safety events from home. Citation Text: Gahn K, Hwang M, Cho Y, et al. Patients' perceptions of using technology for self-reporting cancer medication safety events from home. Stud Health Technol Inform. …

4103. Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned. | PSNet
      psnet.ahrq.gov/issue/anesthesia-adverse-events-voluntarily-reported-veterans-health-administration-and-lessons
      August 21, 2019 - Study Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned. Citation Text: Neily J, Silla ES, Sum-Ping S (J) T, et al. Anesthesia Adverse Events Voluntarily Reported in the Veterans Health Administration and Lessons Learned. Anesth Anal…

4104. Inpatient suicide and suicide attempts in Veterans Affairs hospitals. | PSNet
      psnet.ahrq.gov/issue/inpatient-suicide-and-suicide-attempts-veterans-affairs-hospitals
      January 02, 2017 - Study Inpatient suicide and suicide attempts in Veterans Affairs hospitals. Citation Text: Mills PD, DeRosier JM, Ballot BA, et al. Inpatient suicide and suicide attempts in Veterans Affairs hospitals. Jt Comm J Qual Patient Saf. 2008;34(8):482-488. Copy Citation Format: Go…

4105. Remote patient monitoring during COVID-19: an unexpected patient safety benefit. | PSNet
      psnet.ahrq.gov/issue/remote-patient-monitoring-during-covid-19-unexpected-patient-safety-benefit
      July 20, 2022 - Commentary Remote patient monitoring during COVID-19: an unexpected patient safety benefit. Citation Text: Pronovost PJ, Cole MD, Hughes RM. Remote patient monitoring during COVID-19: an unexpected patient safety benefit. JAMA. 2022;327(12):1125-1126. doi:10.1001/jama.2022.2040. Copy C…

4106. Primary care providers' opening of time-sensitive alerts sent to commercial electronic health record InBaskets. | PSNet
      psnet.ahrq.gov/issue/primary-care-providers-opening-time-sensitive-alerts-sent-commercial-electronic-health-record
      March 17, 2021 - Study Primary care providers' opening of time-sensitive alerts sent to commercial electronic health record InBaskets. Citation Text: Cutrona SL, Fouayzi H, Burns L, et al. Primary Care Providers' Opening of Time-Sensitive Alerts Sent to Commercial Electronic Health Record InBaskets. J Ge…

4107. Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab. | PSNet
      psnet.ahrq.gov/issue/partnership-pathway-diagnostic-excellence-challenges-and-successes-implementing-safer-dx
      April 13, 2022 - Study Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab. Citation Text: Sloane J, Singh H, Upadhyay DK, et al. Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer…

4108. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-11/spotlight_case_neurological_red_flags_final.pptx
      January 01, 2024 - Episodes of Dizziness and Headache A case involving a young adult patient who suffered a stroke causing severe … The patient was left with a severe neurologic deficit. 6 6 Neurological Red Flags: A MISSED STROKE

4109. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33689/psn-pdf
      October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety October 1, 2009 Wachter R. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety Perspective …

4110. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
      March 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case March 2007 Failure to Report Source and Credits This presentation is based on the March 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Patrice L. Spath, BA, RHIT, Brown-Sp…

4111. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49413/psn-pdf
      September 01, 2003 - Did We Forget Something? September 1, 2003 Gibbs VC. Did We Forget Something? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/did-we-forget-something The Case A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially attributed to ventilator-associated pneumo…

4112. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49389/psn-pdf
      February 01, 2003 - Procedural Mishap: Learning Curve? February 1, 2003 Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve The Case A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had undesired fert…

4113. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33779/psn-pdf
      March 01, 2015 - Handoffs and Transitions January 22, 2014 Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/handoffs-and-transitions Annual Perspective 2014 Despite recent efforts to promote clinical integration, the United States health care system remains highly fragmented. From it…

4114. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49727/psn-pdf
      March 01, 2015 - Critical Opportunity Lost March 1, 2015 Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/critical-opportunity-lost The Case A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She reported eating a heavy dinner the pre…

4115. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49438/psn-pdf
      March 05, 2004 - OR Peeping March 1, 2004 Mackenzie CF. OR Peeping. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/or-peeping The Case A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete spontaneous abortion (miscarriage). At this community hospital, a new operating room (OR) su…

4116. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
      January 01, 2020 - Spotlight Spotlight Inpatient Stroke Management in a Patient with Type 1 Diabetes and Home Insulin Pump Source and Credits • This presentation is based on the October 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Berit B…

4117. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33876/psn-pdf
      August 01, 2018 - Building a Safety Program in a Vast Health Care Network March 1, 2019 Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network Perspective Background As hospital-based health care in the United …

4118. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49414/psn-pdf
      September 01, 2003 - Making Do September 1, 2003 Bradley LD. Making Do. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/making-do The Case A 56-year-old female with dysfunctional uterine bleeding and possible retained intrauterine device (IUD) was scheduled for elective hysteroscopy and dilation and curettage (D&C). Of note, sh…

4119. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49826/psn-pdf
      April 01, 2018 - Air on the Side of Caution April 1, 2018 Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/air-side-caution The Case A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of breath and chest pain. A decision was m…

4120. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33659/psn-pdf
      October 01, 2007 - Making Just Culture a Reality: One Organization's Approach October 1, 2007 Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach Perspective We've all been there...something goes wrong,…