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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac
Arrest
September 30, 2020
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
Disclosure of Relevant Financial Relationships: As a pr…
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psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
January 01, 2018 - Because they think, "For any new readers or consultants reading the chart today, I want them to know
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psnet.ahrq.gov/node/42885/psn-pdf
January 22, 2014 - Medication error reporting in rural critical access
hospitals in the North Dakota Telepharmacy Project.
January 22, 2014
Scott DM, Friesner DL, Rathke AM, et al. Medication error reporting in rural critical access hospitals in the
North Dakota Telepharmacy Project. Am J Health Syst Pharm. 2014;71(1):58-67. doi:10.2…
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psnet.ahrq.gov/issue/error-rating-tool-identify-and-analyse-technical-errors-and-events-laparoscopic-surgery
October 09, 2013 - April 21, 2015
Prospective evaluation of consultant surgeon sleep deprivation and outcomes
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psnet.ahrq.gov/issue/handover-after-pediatric-heart-surgery-simple-tool-improves-information-exchange
July 03, 2016 - October 14, 2020
Prospective evaluation of consultant surgeon sleep deprivation and outcomes
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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - Which Line: Ordering Provider or Proceduralist?
March 1, 2019
Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
Case Objectives
Review the role of mistake-proofing to block errors from leading to adverse…
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psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - Last, consultation reports were evidently neither provided by the consultant nor sought by the referring
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psnet.ahrq.gov/node/46722/psn-pdf
March 20, 2018 - Nurses' clinical reasoning practices that support safe
medication administration: an integrative review of the
literature.
March 20, 2018
Rohde E, Domm E. Nurses' clinical reasoning practices that support safe medication administration: An
integrative review of the literature. J Clin Nurs. 2018;27(3-4):e402-e411. …
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - SPOTLIGHT CASE
Delayed Diagnosis of Mesenteric Ischemia
Citation Text:
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Format:
…
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psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - Logo
Delayed Breast Cancer Diagnosis: A False Sense of
Security.
December 23, 2020
Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
The Case
A 60-year-old woman …
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psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
August 31, 2022 - SPOTLIGHT CASE
Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.
Citation Text:
Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/node/60610/psn-pdf
June 24, 2020 - This consultant clearly accepted the
working diagnosis of primary dysmenorrhea and did not pursue further
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - Unseen Perils of Urinary Catheters
Citation Text:
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar Bib…
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psnet.ahrq.gov/web-mm/allergy-holter
May 01, 2008 - Allergy to Holter
Citation Text:
Williams M. Allergy to Holter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - The Forgotten Radiographic Read
Citation Text:
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7…
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psnet.ahrq.gov/node/49833/psn-pdf
June 01, 2018 - Perils in Diagnosing a Stroke
June 1, 2018
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
The Case
A 75-year-old man with a history of hypertension, diabetes, chronic back pain, and opioid use disorder was
brought to the emergency depart…
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psnet.ahrq.gov/node/860050/psn-pdf
January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic
Infant.
January 4, 2024
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
The Case
A 2-month-old full-term male infant was b…
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psnet.ahrq.gov/web-mm/or
August 22, 2013 - "( 2 ) Second, the role played by the cardiology consultant illustrates another missed intervention
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psnet.ahrq.gov/node/73852/psn-pdf
October 27, 2021 - faculty member from the Department of Psychiatry and Behavioral Sciences to
serve as a mental health consultant
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psnet.ahrq.gov/node/49460/psn-pdf
September 01, 2004 - In each instance, fear prevented the student from
reporting the case: concern that a consultant would