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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - have not definitively shown to improve patient outcomes such as electrolyte repletion and avoidable death
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - peritonitis, sepsis, and multi-organ failure progressed postoperatively, ultimately leading to the death
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - natural course of a patient’s illness or underlying condition) that reaches a patient and results in death
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psnet.ahrq.gov/node/49486/psn-pdf
August 21, 2005 - Pharmacist-provided anticoagulation management in United States hospitals:
death rates, length of stay
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psnet.ahrq.gov/node/49811/psn-pdf
November 01, 2017 - was crucial for a condition that, even when diagnosed and treated in a
timely manner, may result in death
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psnet.ahrq.gov/node/49807/psn-pdf
October 01, 2017 - Miscommunications from poor translation can lead to delayed diagnoses and
treatment, causing injury and even death
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psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
September 23, 2024 - that experiencing two or more adverse events was associated with a threefold increase in the risk of death
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - A root cause analysis later attributed the death, at least in part, to inadequate delivery of supplemental
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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - practice among operating room personnel from survey data is associated with all-cause 30-day postoperative death
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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - WebM&M Cases
Medication Mix-Up Leads to Patient Death
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psnet.ahrq.gov/periodic-issue/periodic-issue-317
November 30, 2021 - the delayed or missed recognition of a potentially fatal complication that results in the patient’s death
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psnet.ahrq.gov/node/867429/psn-pdf
December 18, 2024 - persistent pseudomeningocele formation, meningitis, hydrocephalus, arachnoiditis, and, in
rare cases, death … Mixed Defense Ruling Related to
Patient's Death Yield Lessons Regarding Experts.
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psnet.ahrq.gov/glossary
January 01, 2003 - For example, a statewide survey might produce risk-adjusted 30-day rates for death or other major adverse … rescue is shorthand for failure to rescue (i.e., prevent a clinically important deterioration, such as death … An adverse event in which death or serious harm to a patient has occurred; usually used to refer to events
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psnet.ahrq.gov/glossary-0
January 01, 2003 - For example, a statewide survey might produce risk-adjusted 30-day rates for death or other major adverse … rescue is shorthand for failure to rescue (i.e., prevent a clinically important deterioration, such as death … An adverse event in which death or serious harm to a patient has occurred; usually used to refer to events
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psnet.ahrq.gov/periodic-issue/periodic-issue-307
September 29, 2021 - September 1, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, repor…
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psnet.ahrq.gov/periodic-issue/periodic-issue-410
September 27, 2023 - September 27, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, repo…
-
psnet.ahrq.gov/node/49705/psn-pdf
January 01, 2020 - A "Reflexive" Diagnosis in Primary Care
April 1, 2014
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
Case Objectives
Appreciate that primary care doctors may be caring for an increasing number of patients wi…
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - Eptifibatide Epilogue
Citation Text:
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - SPOTLIGHT CASE
Dangerous Dialysis
Citation Text:
Holley JL. Dangerous Dialysis . 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/web-mm/good-catch-operating-room
August 27, 2017 - Good Catch in the Operating Room
Citation Text:
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
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