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  1. The Wet Read | PSNet

    psnet.ahrq.gov/web-mm/wet-read
    October 01, 2017 - department physicians' readings are compared with those of attending radiologists.( 5 ) Nonetheless, concern

  2. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
    January 01, 2024 - earlier, nocturnal headaches that keep patients awake at night should prompt repeat imaging given the concern

  3. Diagnostic Delay in the Emergency Department | PSNet

    psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
    September 18, 2024 - SPOTLIGHT CASE Diagnostic Delay in the Emergency Department Citation Text: Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format:…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33882/psn-pdf
    June 01, 2019 - Building a Safety Program Using Principles of Resilience Engineering June 1, 2019 Hegde S, Fairbanks RJ, Bisantz A. Building a Safety Program Using Principles of Resilience Engineering. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering Persp…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33636/psn-pdf
    July 01, 2006 - Key Issues in Developing a Successful Hospital Safety Program July 1, 2006 Whittington JC. Key Issues in Developing a Successful Hospital Safety Program. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program Perspective What are the key success factors…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49509/psn-pdf
    April 01, 2006 - Insert Omission April 1, 2006 Darney P. Insert Omission. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/insert-omission The Case A multiparous woman presented to the gynecology clinic requesting intrauterine contraceptive (IUC) placement (Figure). She was appropriately counseled on the risks and benefits o…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49667/psn-pdf
    October 01, 2012 - Looking for Meds in All the Wrong Places October 1, 2012 Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places The Case A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She went to t…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33713/psn-pdf
    June 01, 2011 - The Safety of Medical Devices June 1, 2011 Nemeth CP. The Safety of Medical Devices. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/safety-medical-devices Perspective Edward Tenner is right. Technology does have reverberations, including unintended consequences, or "revenge effects."(1) While such dra…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33790/psn-pdf
    August 01, 2015 - New Insights on Safety and Health IT August 1, 2015 Hettinger ZA, Ratwani RM, Fairbanks RJ. New Insights on Safety and Health IT. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/new-insights-safety-and-health-it Perspective Despite the widespread adoption of electronic health records (EHRs) over the las…

  10. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
    November 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case November 2008 Dangerous Shift Source and Credits This presentation is based on the November 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Emily S. Patterson, PhD Institute for Ergonomics, Ohi…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49689/psn-pdf
    August 21, 2013 - Anesthesia: A Weighty Issue August 21, 2013 Sinha AC. Anesthesia: A Weighty Issue. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/anesthesia-weighty-issue The Case A 77-year-old woman was evaluated preoperatively in anticipation of an elective left hip arthroplasty. She reported having a history of hyperte…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867004/psn-pdf
    October 30, 2024 - Critical Radiology Alert Process October 30, 2024 https://psnet.ahrq.gov/innovation/critical-radiology-alert-process Summary Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of unrelated abnormal findings and provides a companion follow-up process, with the goal o…

  13. High Reliability | PSNet

    psnet.ahrq.gov/primer/high-reliability
    January 29, 2020 - High Reliability Citation Text: High Reliability. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downl…

  14. Duty Hours and Patient Safety | PSNet

    psnet.ahrq.gov/primer/duty-hours-and-patient-safety
    June 15, 2024 - Duty Hours and Patient Safety Citation Text: Duty Hours and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

  15. A Laceration that Needed a Proper Exam, Not an X-Ray | PSNet

    psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
    November 25, 2020 - Unless there is concern for infection or an open fracture, it is perfectly acceptable to provide wound

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867805/psn-pdf
    February 26, 2025 - In Conversation with David W. Bates about Are We Safer Today? February 26, 2025 Bates DW, Lee M, Mossburg SE. In Conversation with David W. Bates about Are We Safer Today? PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today Editor’s note: David W. Bates, …

  17. A Lot of Pain (Medications) | PSNet

    psnet.ahrq.gov/web-mm/lot-pain-medications
    September 23, 2020 - SPOTLIGHT CASE A Lot of Pain (Medications) Citation Text: Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49682/psn-pdf
    April 01, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case April 1, 2013 Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premat…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33861/psn-pdf
    July 01, 2018 - RW: I guess that leads to a concern: if you think about what health systems have done to address other

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73102/psn-pdf
    July 01, 2022 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use March 31, 2021 https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail- community-dwelling Summary Care management staff (such …
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