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2061. In Conversation With… Amy J. Starmer, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
      May 31, 2023 - In Conversation With… Amy J. Starmer, MD, MPH April 1, 2016  Citation Text: In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation …

2062. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. | PSNet
      psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
      March 15, 2023 - SPOTLIGHT CASE False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. Citation Text: Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …

2063. A "Reflexive" Diagnosis in Primary Care | PSNet
      psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
      April 01, 2008 - SPOTLIGHT CASE A "Reflexive" Diagnosis in Primary Care Citation Text: Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: …

2064. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36164/psn-pdf
      September 29, 2010 - Recommendations for quality assurance and improvement in surgical and autopsy pathology. September 29, 2010 Pathology A of D of A and S, Nakhleh RE, Coffin C, et al. Recommendations for quality assurance and improvement in surgical and autopsy pathology. Hum Pathol. 2006;37(8):985-8. https://psnet.ahrq.gov/issue/r…

2065. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39904/psn-pdf
      October 13, 2010 - Patient safety: moving the bar in prison health care standards. October 13, 2010 Stern MF, Greifinger RB, Mellow J. Patient safety: moving the bar in prison health care standards. Am J Public Health. 2010;100(11):2103-2110. doi:10.2105/AJPH.2009.184242. https://psnet.ahrq.gov/issue/patient-safety-moving-bar-prison…

2066. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49418/psn-pdf
      October 01, 2003 - Charcoal Lavage of the Lungs October 1, 2003 Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/charcoal-lavage-lungs The Case A 47-year-old man presented to an emergency department (ED) with altered mental status, and was believed to have a probable overdose. He receiv…

2067. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40959/psn-pdf
      November 30, 2011 - Error detection and recovery in dialysis nursing. November 30, 2011 Wilkinson WE, Cauble LA, Patel VL. Error detection and recovery in dialysis nursing. J Patient Saf. 2011;7(4):213-23. doi:10.1097/PTS.0b013e3182388d20. https://psnet.ahrq.gov/issue/error-detection-and-recovery-dialysis-nursing This study found tha…

2068. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43897/psn-pdf
      August 21, 2015 - Guidelines for Adult IV Push Medications. August 21, 2015 Horsham, PA: The Institute for Safe Medication Practices; July 2015. https://psnet.ahrq.gov/issue/guidelines-adult-iv-push-medications To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects applied expert…

2069. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42597/psn-pdf
      December 02, 2014 - Misdiagnosed food allergy resulting in severe malnutrition in an infant. December 2, 2014 Alvares M, Kao L, Mittal V, et al. Misdiagnosed food allergy resulting in severe malnutrition in an infant. Pediatrics. 2013;132(1):e229-32. doi:10.1542/peds.2012-2362. https://psnet.ahrq.gov/issue/misdiagnosed-food-allergy-r…

2070. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47490/psn-pdf
      December 05, 2018 - Check your medical records for dangerous errors. December 5, 2018 Graham J. Kaiser Health News. November 21, 2018. https://psnet.ahrq.gov/issue/check-your-medical-records-dangerous-errors Patients can identify errors in their medical records that health care providers may not recognize. This news article highlight…

2071. Psn-Pdf (pdf file)
      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…

2072. Thin Air | PSNet
      psnet.ahrq.gov/web-mm/thin-air
      March 01, 2006 - SPOTLIGHT CASE Thin Air Citation Text: Gaba DM. Thin Air. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

2073. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49534/psn-pdf
      May 01, 2007 - Antiseizure Medication Disorder May 1, 2007 Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/antiseizure-medication-disorder Case Objectives Appreciate the challenges of safe use of antiepileptic medications. Identify phenytoin toxicity. Understand the pharmaco…

2074. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43293/psn-pdf
      June 25, 2014 - Health-care providers want patients to read medical records, spot errors. June 25, 2014 Landro L. Wall Street Journal. June 9, 2014. https://psnet.ahrq.gov/issue/health-care-providers-want-patients-read-medical-records-spot-errors As they become more prevalent, electronic medical records (EMRs) are being used to i…

2075. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43597/psn-pdf
      November 04, 2014 - The lost art of the history and physical. November 4, 2014 Natt B, Szerlip HM. The lost art of the history and physical. Am J Med Sci. 2014;348(5):423-5. doi:10.1097/MAJ.0000000000000326. https://psnet.ahrq.gov/issue/lost-art-history-and-physical Highlighting concerns about over-reliance on laboratory tests to for…

2076. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43241/psn-pdf
      June 11, 2014 - "It is the left eye, right?" June 11, 2014 Pikkel D, Sharabi-Nov A, Pikkel J. "It is the left eye, right?". Risk Manag Healthc Policy. 2014;7:77-80. doi:10.2147/RMHP.S60728. https://psnet.ahrq.gov/issue/it-left-eye-right In this study, cataract surgeons were asked to identify the correct eye for surgery when given…

2077. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46368/psn-pdf
      October 31, 2017 - A piece of my mind. Trials and tribulations. October 31, 2017 Brown JL. Trials and Tribulations. JAMA. 2017;318(7). doi:10.1001/jama.2017.7106. https://psnet.ahrq.gov/issue/piece-my-mind-trials-and-tribulations Personal experiences can inform understanding of medical error. This commentary describes a physician's …

2078. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45336/psn-pdf
      September 21, 2016 - Medical misdiagnoses put pressure on patients to stay engaged. September 21, 2016 Innes S. Arizona Daily Star. September 12, 2016. https://psnet.ahrq.gov/issue/medical-misdiagnoses-put-pressure-patients-stay-engaged Delayed diagnoses can have serious consequences. This news article reviews several examples of mis…

2079. A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel. | PSNet
      psnet.ahrq.gov/innovation/standardized-marking-procedure-ent-operations-prevent-wrong-site-surgery-development
      February 01, 2013 - EMERGING INNOVATIONS A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel. Citation Text: Rohrmeier C, Abudan Al-Masry N, Keerl R, et al. A standardized marking procedure for ENT…

2080. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36498/psn-pdf
      January 07, 2011 - Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency. January 7, 2011 Baglin TP, Cousins D, Keeling DM, et al. Safety indicators for inpatient and outpatient oral anticoagulant care: [corrected] Recommendations from the British Committee for Standards in Haemat…