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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - A wide variation in the rates of recommendations for additional imaging among radiologists 21
Ambiguity
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - The narrative attributes this delay to ambiguity about who was to arrange the appointment, a phenomenon
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - results19,20:
A wide variation in the rates of recommendations for additional imaging among radiologists21
Ambiguity
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psnet.ahrq.gov/issue/key-cpoe
May 21, 2008 - Newspaper/Magazine Article
The key to CPOE.
Citation Text:
Ross C, Banchy P. The key to CPOE. Health management technology. 2007;28(11):22, 24.
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - Medication Reconciliation Pitfalls
Citation Text:
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
February 15, 2017 - Diuretics and Electrolyte Abnormalities
Citation Text:
Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - Annual Perspective
Rethinking Root Cause Analysis
Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD | January 1, 2016
View more articles from the same authors.
Citation Text:
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. Rockville (MD): Age…
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psnet.ahrq.gov/node/49538/psn-pdf
June 01, 2007 - Abnormal Volunteer Results
June 1, 2007
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results
The Case
A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent
magnetic resonance imaging (MRI) of her abdo…
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psnet.ahrq.gov/node/49484/psn-pdf
June 01, 2005 - Two Pills, Same Drug
June 1, 2005
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/two-pills-same-drug
The Case
A 34-year-old woman with AIDS developed a fever and hypotension due to suspected pneumonia. Her past
medical history included several AIDS-related complica…
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psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - The Missing Suction Tip
November 1, 2003
Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missing-suction-tip
Case Objectives
Identify the risk factors for retained foreign bodies.
Understand methods used to prevent and identify retained foreign bodies.
Apprecia…
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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - "Superficial" Report Leads to "Deep" Problem
Citation Text:
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - There was some role ambiguity regarding supervision and sign-off of completed maintenance jobs, and the
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psnet.ahrq.gov/issue/effort-human-factors-performance-and-decision-making
August 31, 2022 - Commentary
Effort in human factors performance and decision making.
Citation Text:
Wickens CD. Effort in human factors performance and decision making. Hum Factors. 2014;56(8):1329-36.
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psnet.ahrq.gov/issue/integrating-patient-safety-omfs-curriculum-survey-4-year-residency-programs
April 08, 2020 - Study
Integrating patient safety in the OMFS curriculum: survey of 4-year residency programs.
Citation Text:
Buhrow SM, Buhrow JA. Integrating Patient Safety in the OMFS Curriculum: Survey of 4-Year Residency Programs. J Patient Saf. 2016;12(4):197-203.
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psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - Critical Order Set Change and Critical Limb Ischemia
Citation Text:
Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/hiding-plain-sight
April 24, 2019 - Hiding in Plain Sight
Citation Text:
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
November 21, 2021 - Lapse in Antibiotics Leads to Sepsis
Citation Text:
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - The simulated maternal contractions were uncharacteristically smooth, eliminating any ambiguity in their
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psnet.ahrq.gov/issue/practice-makes-perfect-planning-considerations-medical-simulation-centers
December 08, 2010 - Newspaper/Magazine Article
Practice makes perfect: planning considerations for medical simulation centers.
Citation Text:
Ross K. Practice makes perfect. Planning considerations for medical simulation centers. Health Facilities Management. 2012;25(11):23-28.
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…
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psnet.ahrq.gov/web-mm/two-pills-same-drug
May 27, 2011 - Two Pills, Same Drug
Citation Text:
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …