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psnet.ahrq.gov/node/49599/psn-pdf
February 23, 2010 - currently alter
or limit their day-to-day practice activities because of the fear of being sued.(14)
Considering
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psnet.ahrq.gov/node/49399/psn-pdf
May 01, 2003 - All patients considering methotrexate should be screened with a baseline hCG, Rh factor,
complete blood
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Spotlight
Spotlight
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
1
Source and Credits
This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Samantha Brown…
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - whereas ISO sizing typically refers to the internal diameter of the outer cannula, which is useful when considering
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psnet.ahrq.gov/node/866405/psn-pdf
July 31, 2024 - Analysis of an academic medical center’s corrective
action plan in response to fatal medication error using the
Institute for Safe Medication Practices’ Hierarchy of
Effectiveness.
July 31, 2024
Stolte AR, Siwy YM, Tanios SB, et al. Analysis of an academic medical center’s corrective action plan in
response to fa…
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psnet.ahrq.gov/issue/preventing-home-medication-errors
September 15, 2021 - Audiovisual Presentation
Preventing home medication errors.
Citation Text:
Preventing home medication errors. Shaikh U, van der List L, Blumberg D. Kids Considered. March 27, 2023.
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Shar…
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psnet.ahrq.gov/issue/doctors-unconscious-bias-affects-quality-health-care-services-research-shows
October 21, 2020 - Audiovisual
Doctors' unconscious bias affects quality of health care services, research shows.
Citation Text:
Doctors' unconscious bias affects quality of health care services, research shows. Dembosky A. All Things Considered. National Public Radio. October 15, 2020.
Copy Cita…
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psnet.ahrq.gov/issue/some-health-workers-suffering-addiction-steal-drugs-meant-patients
October 28, 2020 - Audiovisual
Some health workers suffering from addiction steal drugs meant for patients.
Citation Text:
Some health workers suffering from addiction steal drugs meant for patients. Mann B. All Things Considered. National Public Radio. October 5, 2020.
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…
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psnet.ahrq.gov/node/33592/psn-pdf
December 15, 2024 - Adverse Events, Near Misses, and Errors
December 15, 2024
Adverse Events, Near Misses, and Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current re…
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psnet.ahrq.gov/node/60795/psn-pdf
August 12, 2020 - Hastened death due to disease burden and distress that
has not received timely, quality palliative care is a medical
error.
August 12, 2020
Gallagher R, Passmore MJ, Baldwin C. Hastened death due to disease burden and distress that has not
received timely, quality palliative care is a medical error. Med Hypotheses…
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psnet.ahrq.gov/node/60232/psn-pdf
April 15, 2020 - Sustaining innovations in complex health care
environments: a multiple-case study of rapid response
teams.
April 15, 2020
Stolldorf DP, Havens DS, Jones CB. Sustaining innovations in complex health care environments: a
multiple-case study of rapid response teams. J Patient Saf. 2020;16(1).
doi:10.1097/pts.0000000…
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psnet.ahrq.gov/node/73465/psn-pdf
July 07, 2021 - Identifying health information technology usability issues
contributing to medication errors across medication
process stages.
July 7, 2021
Adams KT, Pruitt Z, Kazi S, et al. Identifying health information technology usability issues contributing to
medication errors across medication process stages. J Patient Saf…
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psnet.ahrq.gov/node/48086/psn-pdf
June 26, 2019 - Why are patients not more involved in their own safety? A
questionnaire-based survey in a multi-ethnic North
London hospital population.
June 26, 2019
Yoong W, Assassi Z, Ahmedani I, et al. Why are patients not more involved in their own safety? A
questionnaire-based survey in a multi-ethnic North London hospital …
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psnet.ahrq.gov/issue/hospital-ran-out-her-childs-cancer-drug-now-shes-fighting-end-shortages
February 06, 2019 - Newspaper/Magazine Article
The hospital ran out of her child's cancer drug. Now she's fighting to end shortages.
Citation Text:
The hospital ran out of her child's cancer drug. Now she's fighting to end shortages. Noguchi Y. Health Shots and All Things Considered. National Public Ra…
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psnet.ahrq.gov/issue/when-should-multicampus-hospital-be-considered-single-entity-public-reporting-patient-safety
June 28, 2011 - Commentary
When should a multicampus hospital be considered a single entity for public reporting on patient safety issues?
Citation Text:
Naessens JM, Culbertson R, Lefante JJ, et al. When should a multicampus hospital be considered a single entity for public reporting on patient safet…
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psnet.ahrq.gov/issue/patients-views-adverse-events-primary-and-ambulatory-care-systematic-review-assess-methods
December 18, 2017 - Review
Patients' views of adverse events in primary and ambulatory care: a systematic review to assess methods and the content of what patients consider to be adverse events.
Citation Text:
Lang S, Garrido MV, Heintze C. Patients' views of adverse events in primary and ambulatory care: a…
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - related to an offer of
compensation would not be applicable to this case but would be important when considering
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - level, physicians should be aware of, and take action
to address, their cognitive biases such as considering
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/node/44297/psn-pdf
September 09, 2015 - The problem with checklists.
September 9, 2015
Catchpole K, Russ S. The problem with checklists. BMJ Qual Saf. 2015;24(9):545-9. doi:10.1136/bmjqs-
2015-004431.
https://psnet.ahrq.gov/issue/problem-checklists
Checklists, while popularly considered to address safety issues, can be difficult to use reliably. Spotlig…