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psnet.ahrq.gov/node/49461/psn-pdf
September 01, 2004 - Reaction to Dye
September 1, 2004
Cohan R. Reaction to Dye. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/reaction-dye
The Case
A patient was referred to urology after having several episodes of gross hematuria. The urologist thought
that the patient might have a renal mass and sent him to radiology for a…
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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
February 26, 2025 - In Conversation with...Diane Rydrych, MA
June 1, 2007
Citation Text:
In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007.In Conversation with...Diane Rydrych, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department…
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psnet.ahrq.gov/node/40369/psn-pdf
April 13, 2011 - Safety culture in healthcare: a review of concepts,
dimensions, measures and progress.
April 13, 2011
Halligan M, Zecevic A. Safety culture in healthcare: a review of concepts, dimensions, measures and
progress. BMJ Qual Saf. 2011;20(4):338-43. doi:10.1136/bmjqs.2010.040964.
https://psnet.ahrq.gov/issue/safety-cul…
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psnet.ahrq.gov/issue/frequent-diagnostic-errors-cardiac-petct-due-misregistration-ct-attenuation-and-emission-pet
December 22, 2018 - Study
Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT attenuation and emission PET images: a definitive analysis of causes, consequences, and corrections.
Citation Text:
Gould L, Pan T, Loghin C, et al. Frequent diagnostic errors in cardiac PET/CT due to misre…
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psnet.ahrq.gov/web-mm/silent-pain-neck
August 19, 2020 - Silent Pain in the Neck
Citation Text:
Bittner EA. Silent Pain in the Neck. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - In Conversation with...Sorrel King
March 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Sorrel King. PSNet [internet]. 2007.In Conversation with...Sorrel King. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/web-mm/reaction-dye
March 01, 2007 - Reaction to Dye
Citation Text:
Cohan R. Reaction to Dye. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/60269/psn-pdf
April 29, 2020 - Delayed Management of Necrotizing Soft Tissue Infection
– Who does the Patient Belong To?
April 29, 2020
Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the
Patient Belong To? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tiss…
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psnet.ahrq.gov/web-mm/july-syndrome
July 01, 2011 - July Syndrome
Citation Text:
Young JQ. July Syndrome. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
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D…
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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - Failure to Report
March 1, 2007
Spath P. Failure to Report. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/failure-report
Case Objectives
List common causes of medical errors.
Appreciate the magnitude of underreporting of adverse events.
List the common barriers to reporting adverse events and near misses…
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psnet.ahrq.gov/node/33729/psn-pdf
May 01, 2012 - The Emergence of the Trigger Tool as the Premier
Measurement Strategy for Patient Safety
May 1, 2012
Sharek PJ. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety.
PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-pa…
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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a
Patient Admitted for Leg Fractures
March 27, 2024
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
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psnet.ahrq.gov/node/49455/psn-pdf
July 01, 2004 - The Worst Headache
July 1, 2004
Edlow JA. The Worst Headache. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/worst-headache
The Case
A 48-year-old woman with a history of migraine headaches and hypertension presented to her outpatient
clinic with a 4-day history of headache. While shopping 4 days earlier, …
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psnet.ahrq.gov/web-mm/ounce-prevention
February 17, 2011 - SPOTLIGHT CASE
An Ounce of Prevention
Citation Text:
Kucher N. An Ounce of Prevention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/843151/psn-pdf
February 01, 2023 - Patient Safety Concerns and the LGBTQ+ Population
February 1, 2023
Wesley C, Van CM, Mossburg S. Patient Safety Concerns and the LGBTQ+ Population. PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/patient-safety-concerns-and-lgbtq-population
Challenges to Obtaining Needed Patient-Centered and Safe Health…
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psnet.ahrq.gov/node/33744/psn-pdf
February 01, 2013 - In Conversation With… Beverley H. Johnson
February 1, 2013
In Conversation With… Beverley H. Johnson. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
Editor's note: Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient-
and Family-…
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psnet.ahrq.gov/node/39845/psn-pdf
November 02, 2010 - Incidence of medication errors and adverse drug events
in the ICU: a systematic review.
November 2, 2010
Wilmer A, Louie K, Dodek P, et al. Incidence of medication errors and adverse drug events in the ICU: a
systematic review. Qual Saf Health Care. 2010;19(5):e7. doi:10.1136/qshc.2008.030783.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/37183/psn-pdf
October 06, 2011 - Frequent diagnostic errors in cardiac PET/CT due to
misregistration of CT attenuation and emission PET
images: a definitive analysis of causes, consequences,
and corrections.
October 6, 2011
Gould L, Pan T, Loghin C, et al. Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT
attenuation and …
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psnet.ahrq.gov/node/838190/psn-pdf
September 28, 2015 - Use of an expedited review tool to screen for prior
diagnostic error in emergency department patients.
September 28, 2015
Hudspeth J, El-Kareh R, Schiff G. Use of an expedited review tool to screen for prior diagnostic error in
emergency department patients. Appl Clin Inform. 2015;06(04):619-628. doi:10.4338/aci-20…