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  1. The vanishing nonforensic autopsy. | PSNet

    psnet.ahrq.gov/issue/vanishing-nonforensic-autopsy
    February 09, 2011 - Commentary The vanishing nonforensic autopsy. Citation Text: Shojania KG, Burton EC. The vanishing nonforensic autopsy. N Engl J Med. 2008;358(9):873-5. doi:10.1056/NEJMp0707996. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  2. Obstetric Care Consensus No. 5: Severe Maternal Morbidity: Screening and Review. | PSNet

    psnet.ahrq.gov/issue/obstetric-care-consensus-no-5-severe-maternal-morbidity-screening-and-review
    August 20, 2018 - Organizational Policy/Guidelines Obstetric Care Consensus No. 5: Severe Maternal Morbidity: Screening and Review. Citation Text: Obstetric Care Consensus No. 5: Severe Maternal Morbidity: Screening and Review. Obstet Gynecol. 2016;128(3):e54-60. doi:10.1097/AOG.0000000000001642. Copy C…

  3. Cognitive biases associated with medical decisions: a systematic review. | PSNet

    psnet.ahrq.gov/issue/cognitive-biases-associated-medical-decisions-systematic-review
    March 01, 2023 - Review Cognitive biases associated with medical decisions: a systematic review. Citation Text: Saposnik G, Redelmeier DA, Ruff CC, et al. Cognitive biases associated with medical decisions: a systematic review. BMC Med Inform Decis Mak. 2016;16(1):138. Copy Citation Format: …

  4. Cultures of caring: healthcare 'scandals', inquiries, and the remaking of accountabilities. | PSNet

    psnet.ahrq.gov/issue/cultures-caring-healthcare-scandals-inquiries-and-remaking-accountabilities
    September 07, 2022 - Commentary Cultures of caring: healthcare 'scandals', inquiries, and the remaking of accountabilities. Citation Text: Goodwin D. Cultures of caring: Healthcare 'scandals', inquiries, and the remaking of accountabilities. Soc Stud Sci. 2018;48(1):101-124. doi:10.1177/0306312717751051. C…

  5. Diagnostic errors in primary care: lessons learned. | PSNet

    psnet.ahrq.gov/issue/diagnostic-errors-primary-care-lessons-learned
    September 12, 2011 - Study Diagnostic errors in primary care: lessons learned. Citation Text: Ely JW, Kaldjian LC, D'Alessandro DM. Diagnostic errors in primary care: lessons learned. J Am Board Fam Med. 2012;25(1):87-97. doi:10.3122/jabfm.2012.01.110174. Copy Citation Format: DOI Google Scho…

  6. Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog Hospital Safety Grades? | PSNet

    psnet.ahrq.gov/issue/racial-ethnic-and-payer-disparities-adverse-safety-events-are-there-differences-across
    December 01, 2019 - Book/Report Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog Hospital Safety Grades? Citation Text: Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog Hospital Safety Grades? Gangopa…

  7. Delay in Initiating Antibiotics Results in Fatal Error | PSNet

    psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
    August 02, 2015 - SPOTLIGHT CASE Delay in Initiating Antibiotics Results in Fatal Error Citation Text: Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation …

  8. Autopsy Revelation | PSNet

    psnet.ahrq.gov/web-mm/autopsy-revelation
    December 01, 2007 - Autopsy Revelation Citation Text: Shojania KG. Autopsy Revelation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49600/psn-pdf
    April 01, 2010 - Bad Writing, Wrong Medication April 1, 2010 Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication Case Objectives Differentiate between a medication error and an adverse drug event. Appreciate the system complexities involved in medication erro…

  10. Inadequate Preanesthetic Evaluation, Airway Trouble | PSNet

    psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
    November 01, 2023 - Inadequate Preanesthetic Evaluation, Airway Trouble Citation Text: Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar …

  11. Tacit Handover, Overt Mishap | PSNet

    psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
    August 01, 2006 - Tacit Handover, Overt Mishap Citation Text: Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49864/psn-pdf
    June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61078/psn-pdf
    October 28, 2020 - Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump October 28, 2020 Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/inpatient-stroke-management…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49660/psn-pdf
    August 01, 2012 - No News May Not Be Good News August 1, 2012 Moore CR. No News May Not Be Good News. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news Case Objectives Describe the frequency with which ambulatory test results are not followed up by providers. Appreciate that inadequate follow-up of…

  15. The Forgotten Line | PSNet

    psnet.ahrq.gov/web-mm/forgotten-line
    March 11, 2011 - The Forgotten Line Citation Text: Render ML. The Forgotten Line. 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 PubMedId RIS …

  16. Dangerous Dialysis | PSNet

    psnet.ahrq.gov/web-mm/dangerous-dialysis
    June 12, 2024 - SPOTLIGHT CASE Dangerous Dialysis Citation Text: Holley JL. Dangerous Dialysis . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33736/psn-pdf
    September 01, 2012 - In Conversation With… Jack Needleman, PhD September 1, 2012 In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management at UCLA School of P…

  18. One Dose, Two Errors | PSNet

    psnet.ahrq.gov/web-mm/one-dose-two-errors
    September 29, 2017 - One Dose, Two Errors Citation Text: Filice GA. One Dose, Two Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  19. Missed Appendicitis | PSNet

    psnet.ahrq.gov/web-mm/missed-appendicitis
    March 13, 2013 - SPOTLIGHT CASE Missed Appendicitis Citation Text: Adams JG. Missed Appendicitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…

  20. Diagnostic Error | PSNet

    psnet.ahrq.gov/curated-library/diagnostic-error
    September 14, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Error  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Karen Cosby, AHRQ Date Created: May 8, …
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