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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - Radiology Missed an Intracranial Bleed in a Lethargic Infant.
Citation Text:
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - SPOTLIGHT CASE
A Painful Medication Reconciliation Mishap
Citation Text:
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/lethal-vertigo
September 20, 2011 - Lethal Vertigo
Citation Text:
Furman JM. Lethal Vertigo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - Medication Reconciliation Pitfalls
Citation Text:
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/72564/psn-pdf
November 14, 2018 - Antibiotic and Opioid Stewardship in Dentistry
December 7, 2020
Suda KJ, Fitall E, Hall KK, et al. Antibiotic and Opioid Stewardship in Dentistry. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry
Introduction
Medication stewardship refers to efforts by frontlin…
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psnet.ahrq.gov/node/49476/psn-pdf
March 02, 2005 - Around the Block
March 1, 2005
Minichiello T. Around the Block. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/around-block
The Case
A 77-year-old woman with multiple medical problems was admitted to the hospital for an elective knee
replacement. The orthopedic surgeon, recognizing the risk of deep vein th…
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psnet.ahrq.gov/web-mm/amphotericin-toxicity
April 01, 2014 - Amphotericin Toxicity
Citation Text:
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49703/psn-pdf
March 01, 2014 - After-Visit Confusion
March 1, 2014
Ventres W. After-Visit Confusion. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/after-visit-confusion
The Case
An otherwise healthy 18-year-old woman presented to an urgent care clinic with new bumps and white
spots near her tongue. The patient's mother accompanied her …
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - In Conversation With... Heidi Wald, MD
November 26, 2019
Also Read the Essay
Citation Text:
In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.In Conversation With... Heidi Wald, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - Patient Safety in Frail Older Patients
November 26, 2019
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. Rockville (MD): Agency for Healthc…
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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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psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
November 15, 2023 - Hospital at Home℠ Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients.
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April 7, 2021
Innovation…
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case
Citation Text:
Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US …
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - SPOTLIGHT CASE
A Loss of Trust and a Missed Diagnosis
Citation Text:
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - A Postpartum Woman with an Erroneous SARS-CoV-2
Test
April 28, 2021
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
The Case
A full-term pregnant patient was admitted in March 2…
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psnet.ahrq.gov/node/865454/psn-pdf
March 27, 2024 - Ensuring Patient and Workforce Safety Culture in
Healthcare
March 27, 2024
Murray J, Sorra J, Gale B, et al. Ensuring Patient and Workforce Safety Culture in Healthcare. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
Introduction
In 2020, the I…
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - SPOTLIGHT CASE
Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough
Citation Text:
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - SPOTLIGHT CASE
Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery
Citation Text:
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/issue/ibms-watson-learning-its-way-saving-lives
October 18, 2017 - Newspaper/Magazine Article
IBM's Watson is learning its way to saving lives.
Citation Text:
IBM's Watson is learning its way to saving lives. Gertner J. Fast Company. October 15, 2012.
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psnet.ahrq.gov/issue/prone-error-earliest-steps-find-cancer
March 09, 2011 - Newspaper/Magazine Article
Prone to error: earliest steps to find cancer.
Citation Text:
Prone to error: earliest steps to find cancer. Saul S. New York Times. July 19, 2010;A1.
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