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psnet.ahrq.gov/issue/risk-assessment-acute-stroke-diagnostic-process-using-failure-modes-effects-and-criticality
July 21, 2021 - Study
Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.
Citation Text:
Liberman AL, Holl JL, Romo E, et al. Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis. Acad Eme…
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psnet.ahrq.gov/issue/association-surgeon-patient-sex-concordance-postoperative-outcomes
September 09, 2020 - Study
Association of surgeon-patient sex concordance with postoperative outcomes.
Citation Text:
Wallis CJD, Jerath A, Coburn N, et al. Association of surgeon-patient sex concordance with postoperative outcomes. JAMA Surg. 2022;157(2):146-156. doi:10.1001/jamasurg.2021.6339.
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psnet.ahrq.gov/issue/missed-serious-neurologic-conditions-emergency-department-patients-discharged-nonspecific
April 08, 2018 - Study
Missed serious neurologic conditions in emergency department patients discharged with nonspecific diagnoses of headache or back pain.
Citation Text:
Dubosh NM, Edlow JA, Goto T, et al. Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecifi…
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psnet.ahrq.gov/issue/rates-serious-surgical-errors-california-and-plans-prevent-recurrence
March 09, 2022 - Study
Rates of serious surgical errors in California and plans to prevent recurrence.
Citation Text:
Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent recurrence. JAMA Netw Open. 2021;4(5):e217058. doi:10.1001/jamanetworkopen.2021.7058. …
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psnet.ahrq.gov/issue/characteristics-disease-specific-and-generic-diagnostic-pitfalls-qualitative-study
December 02, 2020 - Study
Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study.
Citation Text:
Schiff GD, Volodarskaya M, Ruan E, et al. Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study. JAMA Netw Open. 2022;5(1):e2144531. doi:10.10…
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psnet.ahrq.gov/issue/does-patient-centered-design-guarantee-patient-safety-using-human-factors-engineering-find
November 23, 2016 - Study
Does patient-centered design guarantee patient safety?: Using human factors engineering to find a balance between provider and patient needs.
Citation Text:
France DJ, Throop P, Walczyk B, et al. Does Patient-Centered Design Guarantee Patient Safety? J Patient Saf. 2008;1(3):145-15…
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psnet.ahrq.gov/issue/characteristics-and-unexpected-covid-19-diagnoses-resuscitation-room-patients-during-covid-19
September 02, 2020 - Commentary
Characteristics and unexpected COVID-19 diagnoses in resuscitation room patients during the COVID-19 outbreak - a retrospective case series.
Citation Text:
Bergrath S, Aretz O, Haake H, et al. Characteristics and unexpected COVID-19 diagnoses in resuscitation room patients dur…
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psnet.ahrq.gov/issue/dedicated-teams-optimize-quality-and-safety-surgery-systematic-review
October 27, 2021 - Review
Dedicated teams to optimize quality and safety of surgery: a systematic review.
Citation Text:
Lentz CM, De Lind Van Wijngaarden RAF, Willeboordse F, et al. Dedicated teams to optimize quality and safety of surgery: a systematic review. Int J Qual Health Care. 2022;34(4):mzac078.…
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psnet.ahrq.gov/issue/patterns-medication-incidents-10-yr-experience-cross-national-anaesthesia-incident-reporting
January 15, 2025 - Study
Patterns in medication incidents: a 10-yr experience of a cross-national anaesthesia incident reporting system.
Citation Text:
Sanduende-Otero Y, Villalón-Coca J, Romero-García E, et al. Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident r…
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psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp
October 30, 2019 - For every one of these maternal deaths, there are tens of thousands of cases of avoidable suffering from
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psnet.ahrq.gov/node/60376/psn-pdf
July 30, 2020 - The majority of deaths to date (May 2020) have
been highly concentrated in certain geographic areas,
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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - December 9, 2014
Factors associated with unanticipated day of surgery deaths in Department
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psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - Safety Targets
Recognition of Pediatric Sepsis
Infections have been implicated in 25% of childhood deaths … psnet.ahrq.gov//#25
https://psnet.ahrq.gov//#25
https://psnet.ahrq.gov/issue/algorithm-detects-sepsis-cut-deaths-nearly
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - While
the national average is approximately 20 maternal deaths per 100,000 live births, Arkansas’ rate … psnet.ahrq.gov//mailto:LoweryCurtisL@uams.edu
https://psnet.ahrq.gov//mailto:IDHI@uams.edu
exceeds that at 35 deaths
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - The best estimate from autopsy studies is that there are 40,000 to 80,000
deaths a year from diagnostic … For example the 40,000 to 80,000
deaths a year was just a back-of-the-envelope calculation based on
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psnet.ahrq.gov/web-mm/wrongful-resuscitation
October 12, 2012 - Comparison of military and civilian methods for determining potentially preventable deaths
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.344_slideshow.ppt
April 01, 2015 - PowerPoint Presentation
Spotlight
Dissecting the Presentation
*
This presentation is based on the April 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shirley Beng Suat Ooi, MBBS (S'pore), Emergency Medicine Department, National Univers…
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psnet.ahrq.gov/web-mm/picture-speaks-1000-words
July 16, 2015 - A Picture Speaks 1000 Words
Citation Text:
Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/node/49396/psn-pdf
April 01, 2003 - The 2-Week Itch
April 1, 2003
Cohen MR. The 2-Week Itch. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/2-week-itch
The Case
A 40-year-old woman with bipolar disorder (on trazodone) came to her primary care physician with new
urticaria. She received a handwritten prescription for Zyrtec and Atarax.
The ha…