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psnet.ahrq.gov/node/50434/psn-pdf
September 04, 2019 - Risk of wrong-patient orders among multiple vs singleton
births in the neonatal intensive care units of 2 integrated
health care systems.
September 4, 2019
Adelman JS, Applebaum JR, Southern WN, et al. Risk of Wrong-Patient Orders Among Multiple vs
Singleton Births in the Neonatal Intensive Care Units of 2 Integra…
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing
Citation Text:
Giannini J, Wong M, Dager W, et al. Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
May 01, 2007 - In Conversation with...Sir Liam Donaldson, MD, MSc
May 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Sir Liam Donaldson, MD, MSc. PSNet [internet]. 2007.In Conversation with...Sir Liam Donaldson, MD, MSc. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/primer/handoffs
October 18, 2023 - Handoffs
Citation Text:
Handoffs and Signouts. 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/node/865296/psn-pdf
March 27, 2024 - National Patient Safety Goals
March 27, 2024
Shaikh U. National Patient Safety Goals. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/national-patient-safety-goals
Background
Despite the development and publication of effective and evidence-based strategies to enhance patient
safety and reduce preventable h…
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psnet.ahrq.gov/node/867676/psn-pdf
February 26, 2025 - Responding to Patient Safety Events
February 26, 2025
Shaikh U. Responding to Patient Safety Events. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/responding-patient-safety-events
Background
Patient safety events that occur in health care facilities require prompt action to ensure that further harm is
mit…
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psnet.ahrq.gov/node/74021/psn-pdf
October 25, 2021 - In Conversation With... Georgia Galanou Luchen, Pharm.
D.
October 25, 2021
In Conversation With.. Georgia Galanou Luchen, Pharm. D. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-georgia-galanou-luchen-pharm-d
Editor’s Note: Georgia Galanou Luchen, Pharm. D., is the Director of Member Rela…
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD
August 1, 2012
In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
Editor's note: The topic of patient safety in long-term care facilities has not received the attent…
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psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
September 01, 2017 - Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks
Citation Text:
Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
…
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psnet.ahrq.gov/web-mm/transfusion-overload
September 23, 2020 - SPOTLIGHT CASE
Transfusion Overload
Citation Text:
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/curated-library/artificial-intelligence-system-level-considerations
March 27, 2024 - Breadcrumb
Home
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Curated Libraries
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Artificial Intelligence: System-Level Considerations
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Created By: Lorri Zipper…
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - SPOTLIGHT CASE
Prolonged DKA in Pregnancy: A Case of Communication Breakdown.
Citation Text:
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…
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psnet.ahrq.gov/node/49610/psn-pdf
October 01, 2010 - "Recurrent" Appendicitis
October 1, 2010
Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/recurrent-appendicitis
The Case
An 85-year-old man presented to the emergency department (ED) with right lower quadrant pain. On
physical examination, the patient showed rebound t…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.317_slideshow.ppt
March 01, 2014 - PowerPoint Presentation
Spotlight Case
Tough Call: Addressing Errors From Previous Providers
1
This presentation is based on the March 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: William Martinez, MD, MS, Assistant Professor of Medicine, …
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - Inadvertent Castration
Citation Text:
Calland FJ. Inadvertent Castration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/bowel-prep
March 01, 2017 - Bowel Prep
Citation Text:
Nelson D. Bowel Prep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/walking-patient-missing-drain
April 01, 2006 - Walking Patient, Missing Drain
Citation Text:
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/dont-bite-your-tongue
September 18, 2024 - Don’t Bite Your Tongue.
Citation Text:
Singh NS. Don’t Bite Your Tongue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
November 10, 2025 - Breadcrumb
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Diagnostic Errors Case Studies
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Created By: Maria Mirica, PRIDE Group
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