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psnet.ahrq.gov/issue/safety-0
March 07, 2018 - Multi-use Website
Safety.
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Safety. Center for Health Design.
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June 15, 2016
Center for Heal…
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psnet.ahrq.gov/issue/future-directions-diagnostic-decision-support
February 25, 2019 - Newspaper/Magazine Article
Future directions for diagnostic decision support.
Citation Text:
Future directions for diagnostic decision support. Carr S. ImproveDx. April 2016;3:1-3.
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psnet.ahrq.gov/issue/scottish-audit-surgical-mortality
September 13, 2017 - Multi-use Website
Scottish Audit of Surgical Mortality.
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Scottish Audit of Surgical Mortality. Scottish Audit of Surgical Mortality and Royal College of Physicians and Surgeons of Glasgow.
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psnet.ahrq.gov/issue/working-knowledge-how-organizations-manage-what-they-know
May 24, 2016 - Book/Report
Working Knowledge: How Organizations Manage What They Know.
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Working Knowledge: How Organizations Manage What They Know. Davenport TH, Prusak L. Boston MA: Harvard Business School Press; 1998. ISBN: 0875846556.
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psnet.ahrq.gov/issue/when-missing-zebra-can-land-you-court
August 12, 2015 - Newspaper/Magazine Article
When missing a 'zebra' can land you in court.
Citation Text:
When missing a 'zebra' can land you in court. Crane M. Medscape Business of Medicine. February 20, 2018.
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psnet.ahrq.gov/issue/reminder-pay-attention-appearance-your-medicines
September 09, 2015 - Newspaper/Magazine Article
Reminder: pay attention to the appearance of your medicines.
Citation Text:
Reminder: pay attention to the appearance of your medicines. ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.
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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/node/49708/psn-pdf
May 01, 2014 - Medication Reconciliation With a Twist (or Dare We Say, a
Patch?)
May 1, 2014
Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
Case Objectives
Appreciate that medication discrepanc…
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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.
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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.
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Prone to error: earliest steps to find cancer. Saul S. New York Times. July 19, 2010;A1.
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psnet.ahrq.gov/issue/man-made-disasters-2nd-ed
January 01, 2012 - Book/Report
Classic
Man-Made Disasters. 2nd ed.
Citation Text:
Man-Made Disasters. 2nd ed. Turner BA, Pidgeon NF. Oxford, UK: Butterworth-Heinemann; 1997.
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psnet.ahrq.gov/issue/hamilton-father-misdiagnosed-lung-cancer-demands-answers
September 13, 2017 - Newspaper/Magazine Article
Hamilton father misdiagnosed with lung cancer demands answers.
Citation Text:
Hamilton father misdiagnosed with lung cancer demands answers. Carville O. The Star. November 14, 2014.
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psnet.ahrq.gov/issue/doctor-administered-fatal-dose-calcium-baby-inquest-told
March 06, 2005 - Newspaper/Magazine Article
Doctor administered fatal dose of calcium to baby, inquest told.
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Doctor administered fatal dose of calcium to baby, inquest told. Morris S.
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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 …