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  1. psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
    September 18, 2024 - The ED case review committee analyzed the case in detail and wondered how common diagnostic errors are
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50841/psn-pdf
    January 29, 2020 - maintenance and function checks; (5) assessment of test performance through testing of previously analyzed
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74121/psn-pdf
    November 30, 2021 - colleagues also did a retrospective case-control study of obstetric patients admitted to an ICU and analyzed
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49792/psn-pdf
    May 01, 2017 - The ED case review committee analyzed the case in detail and wondered how common diagnostic errors are
  5. psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
    July 23, 2024 - Data were collected from 2014 to 2018 and analyzed from April 2022 to December 2022. 3 The trial included
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867655/psn-pdf
    February 26, 2025 - Learning Health Systems for Patient Safety February 26, 2025 Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety Despite an observable decrease in adverse events in health care over time, rat…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33825/psn-pdf
    January 01, 2017 - Rethinking Root Cause Analysis January 1, 2016 Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis Annual Perspective 2016 Introduction Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
  8. 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…
  9. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
    June 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case June 2005 Getting to the Root of the Matter Source and Credits This presentation is based on the June 2005 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Scott Flanders, MD; Sa…
  10. 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…
  11. Spotlight Case (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
    May 01, 2006 - Spotlight Case Spotlight Case May 2006 Right? Left? Neither! Source and Credits This presentation is based on the May 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33621/psn-pdf
    November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience November 1, 2005 Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience Perspective Health care organizations throughout the world have ide…
  13. psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me
    May 01, 2019 - Electrocardiogram Results: ***READ ME*** Citation Text: Alpert JS. Electrocardiogram Results: ***READ ME***. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33698/psn-pdf
    August 01, 2010 - In Conversation with...Richard P. Shannon, MD August 1, 2010 In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md Editor's note: Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the University of Pe…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49587/psn-pdf
    May 01, 2009 - Missing Trauma May 1, 2009 Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/missing-trauma The Case A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a few minutes later by a customer, who immediately called 911. On arrival, para…
  16. psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
    December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005  View more articles from the same authors. Citation Text: Conway JB, Weingart SN. Organizational Change…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49805/psn-pdf
    September 01, 2017 - The Forgotten Radiographic Read September 1, 2017 Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read The Case A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for management of inferior…
  18. psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
    August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers Chayan Chakraborti, MD; Marc J. Kahn, MD; N. Kevin Krane, MD | August 1, 2010  Also Read a Conversation View more articles from the same authors. Citation Text: Chakraborti C, Kahn MJ, Krane K. Operatio…
  19. psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
    November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again John Gosbee, MD, MS | November 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Aga…
  20. psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
    September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? Ashish K. Jha, MD, MPH | September 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Jha AK. What Can the Rest of the Heal…

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