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psnet.ahrq.gov/perspective/conversation-christine-cassel-md
February 26, 2025 - In Conversation With… Christine Cassel, MD
June 1, 2015
Citation Text:
In Conversation With… Christine Cassel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting
firm …
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psnet.ahrq.gov/node/49606/psn-pdf
August 01, 2010 - Weighing In on Surgical Safety
August 1, 2010
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/weighing-surgical-safety
Case Objectives
Identify the comorbidites associated with obesity that place patients at higher risk for surgical
complications.
Un…
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - From Pain Relief to Risk: A Case of Suspected Opioid
Overdose in a Pediatric Patient
February 26, 2025
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a
Pediatric Patient. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overd…
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psnet.ahrq.gov/web-mm/emergency-error
January 18, 2013 - SPOTLIGHT CASE
Emergency Error
Citation Text:
Symons NRA. Emergency Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overdose-pediatric-patient
October 04, 2023 - From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient
Citation Text:
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - Annual Perspective
Impact of System Failures on Healthcare Workers
George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD
| March 21, 2023
View more articles from the same authors.
Citation Text:
Zangaro G, Van CM, Mossburg S. Imp…
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose
Citation Text:
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication
Breakdown.
August 30, 2023
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Spotlight
Spotlight
Prolonged DKA in Pregnancy: A Case of Communication
Breakdown
Source and Credits
• This presentation is based on the August 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarah Marshall, MD and Nina M. …
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psnet.ahrq.gov/curated-library/diagnostic-error
August 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Diagnostic Error
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Created By: Karen Cosby, AHRQ
Date Created: May 8, …
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psnet.ahrq.gov/issue/cognitive-forcing-tool-mitigate-cognitive-bias-randomised-control-trial
November 07, 2018 - Study
A cognitive forcing tool to mitigate cognitive bias—a randomised control trial.
Citation Text:
O'Sullivan ED, Schofield SJ. A cognitive forcing tool to mitigate cognitive bias - a randomised control trial. BMC Med Educ. 2019;19(1):12. doi:10.1186/s12909-018-1444-3.
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psnet.ahrq.gov/issue/responding-large-scale-testing-errors
December 18, 2008 - Commentary
Responding to large-scale testing errors.
Citation Text:
Valenstein PN, Alpern GA, Keren DF. Responding to Large-Scale Testing Errors: Table 1. Am J Clin Pathol. 2010;133(3). doi:10.1309/ajcpxlze0yynid0x.
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DOI Google Scholar BibTeX EndNote …
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psnet.ahrq.gov/issue/latency-ecg-displays-hospital-telemetry-systems-science-advisory-american-heart-association
March 14, 2018 - Commentary
Latency of ECG displays of hospital telemetry systems: a science advisory from the American Heart Association.
Citation Text:
Turakhia MP, Estes NAM, Drew BJ, et al. Latency of ECG displays of hospital telemetry systems: a science advisory from the American Heart Association.…
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psnet.ahrq.gov/issue/preventing-medication-errors-community-pharmacy-root-cause-analysis-transcription-errors
March 24, 2011 - Study
Preventing medication errors in community pharmacy: root-cause analysis of transcription errors.
Citation Text:
Knudsen P, Herborg H, Mortensen AR, et al. Preventing medication errors in community pharmacy: root-cause analysis of transcription errors. Qual Saf Health Care. 2007;1…
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psnet.ahrq.gov/issue/development-rating-system-surgeons-non-technical-skills
June 12, 2008 - Study
Development of a rating system for surgeons' non-technical skills.
Citation Text:
Yule S, Flin R, Paterson-Brown S, et al. Development of a rating system for surgeons' non-technical skills. Med Educ. 2006;40(11):1098-104.
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psnet.ahrq.gov/issue/going-solid-model-system-dynamics-and-consequences-patient-safety
August 01, 2018 - Commentary
Classic
"Going solid": a model of system dynamics and consequences for patient safety.
Citation Text:
Cook R, Rasmussen J. "Going solid": a model of system dynamics and consequences for patient safety. Qual Saf Health Care. 2005;14(2):130-4.
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psnet.ahrq.gov/issue/excuse-me-teaching-interns-speak
January 18, 2013 - Study
"Excuse me": teaching interns to speak up.
Citation Text:
O'Connor P, Byrne D, O'Dea A, et al. "Excuse me:" teaching interns to speak up. Jt Comm J Qual Patient Saf. 2013;39(9):426-431.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML En…
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psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective
August 13, 2014 - Study
Managing clinical failure: a complex adaptive system perspective.
Citation Text:
Matthews JI, Thomas PT. Managing clinical failure: a complex adaptive system perspective. Int J Health Care Qual Assur. 2007;20(3):184-194. doi:10.1108/09526860710743336.
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