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psnet.ahrq.gov/node/848109/psn-pdf
April 26, 2023 - Any delay of
appropriate treatment may lead to irreversible consequences.
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psnet.ahrq.gov/web-mm/premature-extubation
May 25, 2011 - extubation and eventual reintubation.( 5 ) Laryngeal edema and postextubation stridor are potential consequences
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psnet.ahrq.gov/node/49582/psn-pdf
April 01, 2009 - https://psnet.ahrq.gov/web-mm/breakage-picc-line
Case Objectives
Appreciate the incidence and consequences
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psnet.ahrq.gov/node/49663/psn-pdf
September 01, 2012 - delayed recognition of
catheter infection by inexperienced staff, until the development of serious consequences
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psnet.ahrq.gov/node/49621/psn-pdf
March 01, 2011 - care unit but did not
https://psnet.ahrq.gov/web-mm/volume-too-low-and-out
experience any long-term consequences
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psnet.ahrq.gov/node/866848/psn-pdf
September 25, 2024 - Those factors
could help them avoid some of the negative unintended consequences of zero harm goals
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psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
August 31, 2020 - decisions, developers need to proactively develop comprehensive mitigation strategies to address unintended consequences … invest in research and evaluation that will enable this purposeful learning risks repeating the tragic consequences
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psnet.ahrq.gov/web-mm/code-status-vs-care-status
September 30, 2020 - For example, a patient may demonstrate appreciation by verbalizing the consequences to themselves by … Cognitive underspecification: Its variety and consequences. In B. J.
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - supplements for a patient on furosemide is routine,
however, this same drug may lead to life-threatening consequences … • Numerous barriers to reporting exist including fear of consequences, a culture of
blame, perception
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psnet.ahrq.gov/node/33628/psn-pdf
February 01, 2006 - In Conversation with…John Banja, PhD
February 1, 2006
In Conversation with…John Banja, PhD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd
Editor's Note: John Banja, PhD, is Assistant Director for Health Sciences and Clinical Ethics and
Associate Professor of Clinical Et…
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psnet.ahrq.gov/node/33634/psn-pdf
May 04, 2006 - The Wild West: Patient Safety in Office-Based Anesthesia
May 1, 2006
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild West: Patient Safety in Office-Based Anesthesia.
PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
Perspective
Over the last decade, sur…
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - Reconciling Records
November 1, 2010
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/reconciling-records
The Cases
Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local
teaching hospital. When discharged, h…
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - Two Wrongs Don't Make a Right (Kidney)
March 1, 2015
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
Case Objectives
Review the current definition of wrong-site surgery.
Describe the incidence of wrong-site surgery, and the…
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psnet.ahrq.gov/node/49808/psn-pdf
October 01, 2017 - High-Risk Medications, High-Risk Transfers
October 1, 2017
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
The Case
A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
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psnet.ahrq.gov/node/49802/psn-pdf
August 01, 2017 - Add-on Case and the Missing Checklist
August 1, 2017
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
The Case
A 65-year-old woman was admitted for evaluation of abdominal pain and weight loss. Based on diagnostic
data and ima…
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psnet.ahrq.gov/node/49680/psn-pdf
March 01, 2013 - Pathologic Mistake
March 1, 2013
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/pathologic-mistake
The Case
A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The
discomfort worsened with eating. After losing 15 pounds …
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psnet.ahrq.gov/node/49394/psn-pdf
April 01, 2003 - Premature or Overdue?
April 1, 2003
Thomas J, Hannah M. Premature or Overdue? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/premature-or-overdue
The Case
A 32-year-old woman, gravida 3, para 1, presented for prenatal care at 24 weeks. Her past medical history
was unremarkable, and results of her prenatal …
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psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - Milliliters vs. Milligrams
December 1, 2010
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
The Case
A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His
evaluation showed acu…
-
psnet.ahrq.gov/perspective/conversation-rebecca-smith-bindman-md
October 01, 2013 - On the other hand, the risks of adverse consequences are often difficult to estimate (they generally
-
psnet.ahrq.gov/perspective/safety-radiology
October 01, 2013 - On the other hand, the risks of adverse consequences are often difficult to estimate (they generally