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psnet.ahrq.gov/node/49514/psn-pdf
July 01, 2006 - One ACE Too Many
July 1, 2006
Juurlink DN. One ACE Too Many. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/one-ace-too-many
The Case
A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure
presented to the emergency department (ED) with chest pain. An acut…
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
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psnet.ahrq.gov/node/33735/psn-pdf
August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and
How to Fix It
August 1, 2012
Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
Perspective
At any point in time, …
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psnet.ahrq.gov/node/49469/psn-pdf
December 01, 2004 - Overriding Considerations
December 1, 2004
Holtzman NA. Overriding Considerations. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/overriding-considerations
The Case
Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic
testing for a variety of condition…
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psnet.ahrq.gov/web-mm/double-dose-transfer
November 01, 2012 - Double Dose at Transfer
Citation Text:
Hackman JL. Double Dose at Transfer. 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/node/33761/psn-pdf
February 01, 2014 - Interruptions and Distractions in Health Care: Improved
Safety With Mindfulness
February 1, 2014
Beyea SC. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness. PSNet
[internet]. 2014.
https://psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulne…
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psnet.ahrq.gov/node/33848/psn-pdf
December 01, 2017 - The Evolution of Patient Safety in Surgery
December 1, 2017
Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
Perspective
In 1979, 20 years before the Institute of Medicine's To Err Is Human report (1) catalyzed the cr…
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psnet.ahrq.gov/node/49563/psn-pdf
May 01, 2008 - Is It Safe to Be Direct?
May 1, 2008
Kulkarni NS, Williams M. Is It Safe to Be Direct? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/it-safe-be-direct
The Case
A 92-year-old man with hypertension and heart failure (HF) was evaluated by his primary care physician
(PCP) for progressive shortness of breat…
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psnet.ahrq.gov/node/60548/psn-pdf
May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD
May 28, 2020
In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at
the Food…
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psnet.ahrq.gov/node/60363/psn-pdf
March 01, 2021 - First Implemented
2002-01-01
Problem Addressed
Recently discharged Medicare patients often suffer complications
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psnet.ahrq.gov/web-mm/other-hand
December 12, 2012 - On the Other Hand
Citation Text:
Henneman EA. On the Other Hand. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
February 26, 2020 - WebM&M Cases
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - checklists: a surgical safety checklist that resulted in more than a one-third decrease in deaths and complications
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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - on being a great place, but when it's publicly reported that we had the second highest rate of these complications
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psnet.ahrq.gov/node/60066/psn-pdf
March 25, 2020 - require immediate intervention to avoid loss of life or limb or serious possibly life-
threatening complications
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psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
March 27, 2024 - suggest diagnoses or evidence-based treatment options or caution against potential treatment-related complications
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psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
March 27, 2024 - suggest diagnoses or evidence-based treatment options or caution against potential treatment-related complications
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psnet.ahrq.gov/node/865373/psn-pdf
March 27, 2024 - In Conversation with...Patrick Tighe about Artificial
Intelligence
March 27, 2024
Tighe P. In Conversation with..Patrick Tighe about Artificial Intelligence . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
Editor's note: Patrick Tighe, MD, MS…
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psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA
April 1, 2010
Also Read an Essay
Citation Text:
In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - Critical Echocardiogram Result Lost to Follow-up
Citation Text:
Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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