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  1. Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors. | PSNet

    psnet.ahrq.gov/issue/clinical-reasoning-education-us-medical-schools-results-national-survey-internal-medicine
    October 12, 2022 - Study Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors. Citation Text: Rencic J, Trowbridge RL, Fagan M, et al. Clinical Reasoning Education at US Medical Schools: Results from a National Survey of Internal Medici…

  2. 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…

  3. 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…

  4. Communication between primary and secondary care: deficits and danger. | PSNet

    psnet.ahrq.gov/issue/communication-between-primary-and-secondary-care-deficits-and-danger
    September 23, 2020 - Study Communication between primary and secondary care: deficits and danger. Citation Text: Dinsdale E, Hannigan A, O’Connor R, et al. Communication between primary and secondary care: deficits and danger. Fam Pract. 2019;17(1):63-68. doi:10.1093/fampra/cmz037. Copy Citation Format…

  5. A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel. | PSNet

    psnet.ahrq.gov/innovation/standardized-marking-procedure-ent-operations-prevent-wrong-site-surgery-development
    February 01, 2013 - EMERGING INNOVATIONS A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel. Citation Text: Rohrmeier C, Abudan Al-Masry N, Keerl R, et al. A standardized marking procedure for ENT…

  6. 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…

  7. 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…

  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/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…

  10. 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…

  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. 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…

  14. 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…

  15. 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…

  16. 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…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37924/psn-pdf
    December 23, 2016 - Behaviors that undermine a culture of safety. December 23, 2016 Behaviors that undermine a culture of safety. Sentinel event alert. 2008;(40):1-3. https://psnet.ahrq.gov/issue/behaviors-undermine-culture-safety The Joint Commission issues sentinel event alerts one to two times yearly to highlight areas of high risk…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837206/psn-pdf
    May 25, 2022 - Automated dispensing cabinet overrides-an evaluation of necessity in a pediatric emergency department. May 25, 2022 Paterson EP, Manning KB, Schmidt MD, et al. Automated dispensing cabinet overrides-an evaluation of necessity in a pediatric emergency department. J Emerg Nurs. 2022;48(3):319-327. doi:10.1016/j.jen.…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46304/psn-pdf
    November 01, 2017 - Comparative performance of pediatric weight estimation techniques: a human factor errors analysis. November 1, 2017 Abdel-Rahman SM, Jacobsen R, Watts JL, et al. Comparative performance of pediatric weight estimation techniques: a human factor errors analysis. Pediatr Emerg Care. 2015;33(8):548-552. doi:10.1097/pe…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60230/psn-pdf
    April 15, 2020 - Optimizing patient safety in clinical trials by improving transitions of care. April 15, 2020 Nair SC, Satish KP, Al Maini M, et al. Optimizing patient safety in clinical trials by improving transitions of care. Jt Comm J Qual Patient Saf. 2020;46(4). doi:10.1016/j.jcjq.2020.01.001. https://psnet.ahrq.gov/issue/op…
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