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1. WebM&M: Case Studies | PSNet
   psnet.ahrq.gov/webmm-case-studies
   February 26, 2025 - WebM&M: Case Studies WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical … Submit Your Case All WebM&M: Case Studies (662)

2. Case studies on medication reconciliation. | PSNet
   psnet.ahrq.gov/issue/case-studies-medication-reconciliation
   February 15, 2023 - Special or Theme Issue Case studies on medication reconciliation. … Citation Text: Case studies on medication reconciliation. Crawford AG; Sciamanna CN. … The journal provides an editorial and several case studies on medication reconciliation from a variety … Linkedin Copy URL Cite Citation Citation Text: Case studies … June 2, 2021 Radiologists make more errors interpreting off-hours body CT studies during

3. Diagnostic Errors Case Studies | PSNet
   psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
   March 24, 2025 - The PSNet Collection Curated Libraries Subscribed Diagnostic Errors Case Studies … Through the PRIDE Learning Network, diagnostic error case studies were reviewed to identify common pitfalls … These de-identified case studies are free to view and available through this Curated Library.

4. AHRQ Impact Case Studies: Patient Safety. | PSNet
   psnet.ahrq.gov/issue/ahrq-impact-case-studies-patient-safety
   October 23, 2019 - Multi-use Website AHRQ Impact Case Studies: Patient Safety. … Citation Text: AHRQ Impact Case Studies: Patient Safety. … This collection of case studies highlights AHRQ-funded patient safety tools, including the Comprehensive … Copy URL Cite Citation Citation Text: AHRQ Impact Case Studies

5. Evidence of bias and variation in diagnostic accuracy studies. | PSNet
   psnet.ahrq.gov/issue/evidence-bias-and-variation-diagnostic-accuracy-studies
   February 15, 2023 - Review Evidence of bias and variation in diagnostic accuracy studies. … Evidence of bias and variation in diagnostic accuracy studies. … This review identified 31 meta-analyses with 487 studies of test evaluation. … greatly impacted estimated accuracy, highlighting the importance of considering design when conducting studies … Evidence of bias and variation in diagnostic accuracy studies.

6. Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies. | PSNet
   psnet.ahrq.gov/issue/postoperative-adverse-events-inconsistently-improved-world-health-organization-surgical
   March 29, 2023 - improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies … However, subsequent studies failed to reproduce these results, engendering controversy about the true … The authors also noted that the reported effect of the checklist was incongruous—in several studies, … These concerns, along with methodological problems in many of the included studies, led the authors to … postulate that the observed improvements seen in some studies may have been due to temporal changes

7. Algorithm based smartphone apps to assess risk of skin cancer in adults: systematic review of diagnostic accuracy studies. | PSNet
   psnet.ahrq.gov/issue/algorithm-based-smartphone-apps-assess-risk-skin-cancer-adults-systematic-review-diagnostic
   July 29, 2020 - based smartphone apps to assess risk of skin cancer in adults: systematic review of diagnostic accuracy studies … based smartphone apps to assess risk of skin cancer in adults: systematic review of diagnostic accuracy studies … varied widely across studies. … The authors note limitations of the included studies, such as failure to recruit a population representative … Findings are consistent with earlier studies reporting poor performance of smartphone apps for melanoma

8. Artificial intelligence versus clinicians: systematic review of design, reporting standards, and claims of deep learning studies. | PSNet
   psnet.ahrq.gov/issue/artificial-intelligence-versus-clinicians-systematic-review-design-reporting-standards-and
   May 20, 2019 - intelligence versus clinicians: systematic review of design, reporting standards, and claims of deep learning studies … intelligence versus clinicians: systematic review of design, reporting standards, and claims of deep learning studies … Although 61 of 81 published studies reported that AI performance was comparable or better than that of … clinicians, the authors identified few prospective studies or studies conducted in real-world settings … Future studies examining the impact of AI in medicine must decrease risk of bias, increase relevance

9. Scoping review of studies evaluating frailty and its association with medication harm. | PSNet
   psnet.ahrq.gov/issue/scoping-review-studies-evaluating-frailty-and-its-association-medication-harm
   May 25, 2022 - Review Scoping review of studies evaluating frailty and its association with medication … Scoping review of studies evaluating frailty and its association with medication harm. … This scoping review shows that studies evaluating medication harm in frail patients are largely limited … The authors discuss the need for more robust studies examining this relationship, including the effect … Scoping review of studies evaluating frailty and its association with medication harm.

10. New Horizons in Patient Safety: Understanding Communication: Case Studies for Physicians. | PSNet
    psnet.ahrq.gov/issue/new-horizons-patient-safety-understanding-communication-case-studies-physicians
    December 15, 2021 - Book/Report New Horizons in Patient Safety: Understanding Communication: Case Studies … Citation Text: New Horizons in Patient Safety: Understanding Communication: Case Studies for Physicians … publication discusses factors that influence communication in the medical care process and uses case studies … Citation Citation Text: New Horizons in Patient Safety: Understanding Communication: Case Studies … Safe Communication: Evidence-based Core Competencies with Case Studies from Nursing.

11. Committed to Safety: Ten Case Studies on Reducing Harm to Patients. | PSNet
    psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients
    July 31, 2012 - Book/Report Committed to Safety: Ten Case Studies on Reducing Harm to Patients. … Citation Text: Committed to Safety: Ten Case Studies on Reducing Harm to Patients. … This report presents ten case studies to illustrate interventions that address prominent and targeted … The authors also published an article about case studies in safety improvement. … July 31, 2012 Stories from the sharp end: case studies in safety improvement.

12. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. | PSNet
    psnet.ahrq.gov/issue/diagnostic-errors-intensive-care-unit-systematic-review-autopsy-studies
    March 10, 2021 - Review Diagnostic errors in the intensive care unit: a systematic review of autopsy studies … Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. … This systematic review of autopsy studies sought to estimate the incidence of diagnostic errors contributing … This review, which included 31 separate studies, found an overall class I error rate of 8% in ICU patients … Diagnostic errors in the intensive care unit: a systematic review of autopsy studies.

13. Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies. | PSNet
    psnet.ahrq.gov/issue/determining-skills-needed-frontline-nhs-staff-deliver-quality-improvement-findings-six-case
    March 30, 2022 - Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies … Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies … Using case studies and qualitative interviews, this study outlines six “socio-organisational functional … Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies … 2022 Applying thematic synthesis to interpretation and commentary in epidemiological studies

14. Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies. | PSNet
    psnet.ahrq.gov/issue/speaking-behaviours-safety-voices-healthcare-workers-metasynthesis-qualitative-research
    June 23, 2021 - Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies … Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies … This review of studies identified hierarchy and role expectations as barriers to nurses speaking up and … Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies … psychological experiences of nurses after inpatient suicide: a meta-synthesis of qualitative research studies

15. Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies. | PSNet
    psnet.ahrq.gov/issue/trends-diagnostic-adverse-events-hospital-deaths-longitudinal-analyses-four-retrospective
    May 18, 2022 - diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies … diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies … can provide insights into incidence, preventability, and causes not easily found in cross-sectional studies … Data from four studies that included 19-20 hospitals were analyzed to estimate the occurrence of diagnostic … diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies

16. Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge. | PSNet
    psnet.ahrq.gov/issue/pending-studies-hospital-discharge-pre-post-analysis-electronic-medical-record-tool-improve
    September 16, 2020 - Study Pending studies at hospital discharge: a pre-post analysis of an electronic … Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve … The introduction of a tool that automatically generates a list of studies pending at discharge improved … communication of pending studies from 18% to 43%. … Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve

17. Strategies for improving the value of the radiology report: a retrospective analysis of errors in formally over-read studies. | PSNet
    psnet.ahrq.gov/issue/strategies-improving-value-radiology-report-retrospective-analysis-errors-formally-over-read
    November 10, 2021 - improving the value of the radiology report: a retrospective analysis of errors in formally over-read studies … improving the value of the radiology report: a retrospective analysis of errors in formally over-read studies … This retrospective review of imaging studies submitted to a second institution for a second interpretation … improving the value of the radiology report: a retrospective analysis of errors in formally over-read studies … August 18, 2021 Radiologists make more errors interpreting off-hours body CT studies

18. Diagnostic accuracy of a large language model in pediatric case studies. | PSNet
    psnet.ahrq.gov/issue/diagnostic-accuracy-large-language-model-pediatric-case-studies
    May 25, 2016 - Study Diagnostic accuracy of a large language model in pediatric case studies. … Diagnostic accuracy of a large language model in pediatric case studies. … asked ChatGPT to provide a differential diagnosis list and final diagnosis for 100 pediatric case studies … Diagnostic accuracy of a large language model in pediatric case studies.

19. Patient and Family Engagement in Primary Care: Case Studies. | PSNet
    psnet.ahrq.gov/issue/patient-and-family-engagement-primary-care-case-studies
    November 01, 2016 - Book/Report Patient and Family Engagement in Primary Care: Case Studies. … Citation Text: Patient and Family Engagement in Primary Care: Case Studies. … This guide includes case studies that explore how Open Notes , team-based care delivery, and patient … Cite Citation Citation Text: Patient and Family Engagement in Primary Care: Case Studies

20. Handoff mnemonics used in perioperative handoff intervention studies: a systematic review. | PSNet
    psnet.ahrq.gov/issue/handoff-mnemonics-used-perioperative-handoff-intervention-studies-systematic-review
    November 16, 2022 - Review Handoff mnemonics used in perioperative handoff intervention studies: a systematic … Handoff mnemonics used in perioperative handoff intervention studies: a systematic review. … Most studies reported only on process outcomes; only four measured patient outcomes. … Handoff mnemonics used in perioperative handoff intervention studies: a systematic review.