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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
January 01, 2024 - for 1.2% of annual visits to emergency departments and is the
eighth leading cause of preventable death
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - The cause of death was documented as hip trauma from the fall at the nursing home.
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - consecutive falls and is associated with longer hospital stays, increased frequency of in-hospital death
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - patients worries about the harm we inflict on patients when we’re trying at all costs to prevent a death
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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - patients worries about the harm we inflict on patients when we’re trying at all costs to prevent a death
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psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis
May 26, 2021 - April 7, 2021
Hastened death due to disease burden and distress that has not received
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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - characteristics, studies have shown that missed nursing care is correlated with an increased risk of death
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psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
December 18, 2024 - responsible for 1.2% of annual visits to emergency departments and is the eighth leading cause of preventable death
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psnet.ahrq.gov/node/864867/psn-pdf
April 10, 2024 - for 1.2% of annual visits to emergency departments
and is the eighth leading cause of preventable death
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psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
January 29, 2021 - WebM&M Cases
When Vomit Gets in the Way: Aspiration Resulting in Death
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psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
April 24, 2024 - characteristics, studies have shown that missed nursing care is correlated with an increased risk of death
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psnet.ahrq.gov/node/33776/psn-pdf
January 01, 2015 - In Conversation With… Mark Graban, MS, MBA
January 1, 2015
In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
Editor's note: Mark Graban, MS, MBA, is an internationally recognized expert in Lean Healthcare, which
has become one of…
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psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - SPOTLIGHT CASE
The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy
Citation Text:
Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
June 14, 2023 - Management of Cardiac Arrest in Unconventional Locations.
Citation Text:
Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations.. 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/web-mm/updates-management-high-risk-pulmonary-embolism
December 02, 2020 - Updates in the Management of High-Risk Pulmonary Embolism
Citation Text:
Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Forma…
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psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - 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 was se…
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psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
September 09, 2013 - SPOTLIGHT CASE
Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care
Citation Text:
Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/node/865413/psn-pdf
March 27, 2024 - In Conversation with...Barbara Pelletreau and John Riggi
about Cybersecurity
March 27, 2024
Pelletreau B, Riggi J. In Conversation with..Barbara Pelletreau and John Riggi about Cybersecurity. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cyberse…
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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/33833/psn-pdf
May 01, 2017 - In Conversation With… David Juurlink, MD, PhD
May 1, 2017
In Conversation With… David Juurlink, MD, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
Editor's note: Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of
Toronto, w…