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psnet.ahrq.gov/web-mm/transfer-or-not-transfer
November 23, 2016 - SPOTLIGHT CASE
To Transfer or Not to Transfer
Citation Text:
Pines JM. To Transfer or Not to Transfer. 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/continuing-education
February 26, 2025 - Continuing Education
What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
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psnet.ahrq.gov/curated-library/diagnostic-error
August 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Diagnostic Error
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Created By: Karen Cosby, AHRQ
Date Created: May 8, …
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psnet.ahrq.gov/node/861880/psn-pdf
January 31, 2024 - Patient and Family Centered I-PASS (Family-Centered
Communication Program to Reduce Medical Errors and
Improve Family Experience and Communication
Processes)
January 31, 2024
https://psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-
program-reduce-medical
Summary
Medica…
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psnet.ahrq.gov/web-mm/dependence-vs-pain
October 30, 2019 - according to the DAWN Mortality Data Report, hydrocodone ranked among the 10 most common drugs related to deaths … Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - Hanging, strangulation, and asphyxiation together accounted for about 60% of attempts and 24 deaths. … The second most common method was cutting with a sharp object, contributing to 23% of attempts but no deaths
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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - enhance cockpit performance of helicopter pilots in
operation “Desert Storm” in Iraq, “friendly fire” deaths … US pilots blame drug for friendly fire deaths. The Guardian. January 4, 2003.
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - enhance cockpit performance of helicopter pilots in operation “Desert Storm” in Iraq, “friendly fire” deaths … US pilots blame drug for friendly fire deaths. The Guardian. January 4, 2003.
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - Lung cancer is the leading cause of cancer deaths and must be considered in patients with historical … the concern that overprescribing opioids has contributed to the current epidemic of opioid overdose deaths
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - time.( 14 ) Misdiagnoses are estimated to account for approximately 40,000–80,000 preventable hospital deaths … treatment or through the application of incorrect treatments.( 1 ) This estimate accounts neither for deaths
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - had implemented a system that had a specific purpose, and it was extremely successful at preventing deaths … patient safety issue in the inpatient setting; research estimates between 10% and 13% of patient hospital deaths
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psnet.ahrq.gov/issue/seeking-answers-hearing-silence
October 09, 2024 - Commentary
Seeking answers, hearing silence.
Citation Text:
Hemmelgarn C. Seeking Answers, Hearing Silence. Health Aff (Millwood). 2018;37(8):1332-1334. doi:10.1377/hlthaff.2017.1535.
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psnet.ahrq.gov/issue/development-national-reporting-and-learning-system-england-and-wales-2001-2005
September 14, 2022 - Commentary
The development of the National Reporting and Learning System in England and Wales, 2001-2005.
Citation Text:
Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and Wales, 2001–2005. Med J Aust. 2019;184(S10) (S10):s65-s68. doi:1…
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psnet.ahrq.gov/issue/using-automated-risk-assessment-report-identify-patients-risk-clinical-deterioration
February 15, 2017 - Commentary
Using an automated risk assessment report to identify patients at risk for clinical deterioration.
Citation Text:
Whittington J, White R, Haig KM, et al. Using an automated risk assessment report to identify patients at risk for clinical deterioration. Jt Comm J Qual Patient S…
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psnet.ahrq.gov/issue/beyond-communication-role-standardized-protocols-changing-health-care-environment
October 12, 2011 - Study
Beyond communication: the role of standardized protocols in a changing health care environment.
Citation Text:
Vardaman JM, Cornell P, Gondo MB, et al. Beyond communication: the role of standardized protocols in a changing health care environment. Health Care Manage Rev. 2012;37…
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psnet.ahrq.gov/issue/intrathecal-chemotherapy-potential-medication-error
February 23, 2015 - Review
Intrathecal chemotherapy: potential for medication error.
Citation Text:
Gilbar PJ. Intrathecal chemotherapy: potential for medication error. Cancer Nurs. 2014;37(4):299-309. doi:10.1097/NCC.0000000000000108.
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psnet.ahrq.gov/issue/what-prevents-incident-disclosure-and-what-can-be-done-promote-it
February 20, 2012 - Study
What prevents incident disclosure, and what can be done to promote it?
Citation Text:
Iedema R, Allen S, Sorensen R, et al. What prevents incident disclosure, and what can be done to promote it? Jt Comm J Qual Patient Saf. 2011;37(9):409-417.
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psnet.ahrq.gov/issue/achieving-meaningful-use-health-information-technology-guide-physicians-ehr-incentive
June 09, 2021 - Commentary
Achieving meaningful use of health information technology: a guide for physicians to the EHR Incentive Programs.
Citation Text:
Seidman J. Achieving meaningful use of health information technology: a guide for physicians to the EHR Incentive Programs. Arch Intern Med. 2012;172…