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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46213/psn-pdf
    June 28, 2017 - The second victim: a review. June 28, 2017 Coughlan B, Powell D, Higgins MF. The Second Victim: a Review. Eur J Obstet Gynecol Reprod Biol. 2017;213:11-16. doi:10.1016/j.ejogrb.2017.04.002. https://psnet.ahrq.gov/issue/second-victim-review Maternity care is a high-risk environment. This review discusses second vic…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60065/psn-pdf
    March 18, 2020 - Safety in Numbers: Hospital Performance on Leapfrog’s Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital Survey. March 18, 2020 Washington DC: Leapfrog Group; 2020. https://psnet.ahrq.gov/issue/safety-numbers-hospital-performance-leapfrogs-surgical-volume-standard- based-results-2019 Surgica…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60746/psn-pdf
    July 29, 2020 - Misdiagnosis of a Pelvic Mass versus Pregnancy July 29, 2020 Leiserowitz GS, Herding H. Misdiagnosis of a Pelvic Mass versus Pregnancy. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy The Case A 28-year-old woman arrived at the Emergency Department (ED) complaining o…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49709/psn-pdf
    May 01, 2014 - Raise the Bar May 1, 2014 Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/raise-bar The Case A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The patient was seen and evaluated by an anesthesiologist who was new to the cente…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866846/psn-pdf
    September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 24, 2024 Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/zero…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49424/psn-pdf
    November 01, 2003 - Waiting Too Long November 1, 2003 Rosen MA. Waiting Too Long. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/waiting-too-long The Case A 31-year-old gravida 1, para 1 woman presented at 40 weeks in the early stages of labor having received limited prenatal care at an outside clinic. Physical exam performed…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49391/psn-pdf
    February 01, 2003 - When "Psychiatric" Symptoms Are Not February 1, 2003 Goldberg RJ. When "Psychiatric" Symptoms Are Not. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not The Case A 70-year-old man without documented past psychiatric history was placed on an involuntary hold as a danger to oth…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49680/psn-pdf
    March 01, 2013 - Pathologic Mistake March 1, 2013 Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pathologic-mistake The Case A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The discomfort worsened with eating. After losing 15 pounds …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49851/psn-pdf
    January 01, 2019 - One Bronchoscopy, Two Errors January 1, 2019 Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors The Case A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic respiratory failure…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49601/psn-pdf
    April 01, 2010 - Nosy Business April 1, 2010 Orlandi RR. Nosy Business. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/nosy-business The Case   A 59-year-old man with a history of idiopathic thrombocytopenic purpura (ITP) presented to the emergency department (ED) with epistaxis (a "nose bleed"). He reported no previous h…

  11. Misleading Complaint | PSNet

    psnet.ahrq.gov/web-mm/misleading-complaint
    December 01, 2009 - Misleading Complaint Citation Text: Soni K, Dhaliwal G. Misleading Complaint. 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 XML EndNote 7 XML Endnote tagged …

  12. Individual Clinician Performance Issues | PSNet

    psnet.ahrq.gov/primer/individual-clinician-performance-issues
    March 15, 2025 - Individual Clinician Performance Issues Citation Text: Individual Clinician Performance Issues. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  13. Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism in preventing infection caused by accompanying caregivers during COVID-19-experience of a city medical center in Taiwan. | PSNet

    psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-hfmea-effective-mechanism-preventing-infection
    April 05, 2023 - Study Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism in preventing infection caused by accompanying caregivers during COVID-19-experience of a city medical center in Taiwan. Citation Text: Tiao C-H, Tsai L-C, Chen L-C, et al. Healthcare Failure Mode and Eff…

  14. Long-term outcomes of medication intervention using the screening tool of older persons potentially inappropriate prescriptions screening tool to alert doctors to right treatment criteria. | PSNet

    psnet.ahrq.gov/issue/long-term-outcomes-medication-intervention-using-screening-tool-older-persons-potentially
    July 31, 2024 - Study Long-term outcomes of medication intervention using the screening tool of older persons potentially inappropriate prescriptions screening tool to alert doctors to right treatment criteria. Citation Text: Frankenthal D, Israeli A, Caraco Y, et al. Long-Term Outcomes of Medication In…

  15. Understanding and preventing wrong-patient electronic orders: a randomized controlled trial. | PSNet

    psnet.ahrq.gov/issue/understanding-and-preventing-wrong-patient-electronic-orders-randomized-controlled-trial
    December 21, 2017 - Study Understanding and preventing wrong-patient electronic orders: a randomized controlled trial. Citation Text: Adelman JS, Kalkut GE, Schechter CB, et al. Understanding and preventing wrong-patient electronic orders: a randomized controlled trial. J Am Med Inform Assoc. 2013;20(2):305…

  16. Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care unit: a stepped-wedge cluster randomized clinical trial. | PSNet

    psnet.ahrq.gov/issue/effect-standardized-handoff-curriculum-improved-clinician-preparedness-intensive-care-unit
    October 19, 2022 - Study Classic Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care unit: a stepped-wedge cluster randomized clinical trial. Citation Text: Parent B, LaGrone LN, Albirair MT, et al. Effect of Standardized Handoff Curr…

  17. A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study. | PSNet

    psnet.ahrq.gov/issue/partially-structured-postoperative-handoff-protocol-improves-communication-2-mixed-surgical
    November 19, 2018 - Study A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study. Citation Text: Lane-Fall MB, Pascual JL, Peifer HG, et al. A Partia…

  18. Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems. | PSNet

    psnet.ahrq.gov/issue/risk-wrong-patient-orders-among-multiple-vs-singleton-births-neonatal-intensive-care-units-2
    December 21, 2017 - Study Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems. Citation Text: Adelman JS, Applebaum JR, Southern WN, et al. Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Int…

  19. Relationship between state malpractice environment and quality of health care in the United States. | PSNet

    psnet.ahrq.gov/issue/relationship-between-state-malpractice-environment-and-quality-health-care-united-states
    June 21, 2017 - Study Relationship between state malpractice environment and quality of health care in the United States. Citation Text: Bilimoria KY, Chung JW, Minami CA, et al. Relationship Between State Malpractice Environment and Quality of Health Care in the United States. Jt Comm J Qual Patient Sa…

  20. Safety of the Manchester Triage System to detect critically ill children at the emergency department. | PSNet

    psnet.ahrq.gov/issue/safety-manchester-triage-system-detect-critically-ill-children-emergency-department
    October 18, 2023 - Study Safety of the Manchester Triage System to detect critically ill children at the emergency department. Citation Text: Zachariasse JM, Kuiper JW, de Hoog M, et al. Safety of the Manchester Triage System to Detect Critically Ill Children at the Emergency Department. J Pediatr. 2016;17…
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