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psnet.ahrq.gov/node/49744/psn-pdf
October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced
Hemolysis in a Patient With a Known Allergy
October 1, 2015
Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known
Allergy. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…
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psnet.ahrq.gov/node/33785/psn-pdf
May 01, 2015 - In Conversation With… John D. Birkmeyer, MD
May 1, 2015
In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
Editor's note: John D. Birkmeyer, MD, is an internationally recognized health services researcher with
expertise in perfo…
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care
Source and Credits
• This presentation is based on the 2020 AHRQ WebM&M Spotlight
Case
○ See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD
○ Editor…
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psnet.ahrq.gov/node/33879/psn-pdf
May 01, 2019 - In Conversation With… Jane Brice, MD, MPH
May 1, 2019
In Conversation With… Jane Brice, MD, MPH. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
Editor's note: Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University
of North Carolina. She…
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psnet.ahrq.gov/web-mm/slippery-slide-life
January 21, 2017 - Slippery Slide Into Life
Citation Text:
Halamek LP. Slippery Slide Into Life. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Right Patient, Wrong Sample
December 1, 2006
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample
The Case
A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On
the morning of surgery, the patien…
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psnet.ahrq.gov/node/49618/psn-pdf
February 01, 2011 - One Toxic Drug Is Not Like Another
February 1, 2011
Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
Case Objectives
Distinguish between the three distinct regulatory processes of board certification, medical licensure,
and credential…
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psnet.ahrq.gov/node/863308/psn-pdf
February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in
Death During Endoscopy
February 28, 2024
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
The Case
A…
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart
Save
Save to your library
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June 12, 2020
…
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psnet.ahrq.gov/node/33690/psn-pdf
December 01, 2009 - In Conversation with…Gerald B. Hickson, MD
December 1, 2009
In Conversation with…Gerald B. Hickson, MD . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
Editor's note: Gerald B. Hickson, MD, is one of the world's leading experts on physician behavior and its
connecti…
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psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
March 31, 2021 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?
Citation Text:
Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/Information/Editor
May 23, 2025 - Browse Author Resources
Meet PSNet's Editorial Team The PSNet editorial team is committed to producing the highest quality patient safety content. The team brings a wealth of experience and deep subject matter expertise in the field, ensuring that PSNet content is accurate, reliable, and…
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - But See the Patient First
January 29, 2021
Sinigayan VR. But See the Patient First. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/see-patient-first
The Case
A 55-year-old man with acute myeloid leukemia presented to the emergency department (ED) with a chief
complaint of fever. Five days previously, he …
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psnet.ahrq.gov/node/33792/psn-pdf
September 01, 2015 - In Conversation With… Eric J. Topol, MD
September 1, 2015
In Conversation With… Eric J. Topol, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
Editor's note: Eric J. Topol, MD, is Director of Scripps Translational Science Institute, Professor of
Genomics at The Scripps …
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psnet.ahrq.gov/node/49765/psn-pdf
August 21, 2016 - Cognitive Overload in the ICU
August 21, 2016
Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/cognitive-overload-icu
Case Objectives
Identify the role of cognitive overload—especially interruptions—in compromising quality of care and
patient safety.
List…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest
Citation Text:
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - Verbal Orders and Medication Overrides: A Dangerous Combination
Citation Text:
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - SPOTLIGHT CASE
Near Miss with Bedside Medications
Citation Text:
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - Nursing and Patient Safety
Citation Text:
Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. 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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