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1301. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. | PSNet
      psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
      October 31, 2023 - June 24, 2020 The many faces of error disclosure: a common set of elements and a definition

1302. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852700/psn-pdf
      August 30, 2023 - It’s time for us expand our definition of harm beyond harms that are physical to those that are  psychological

1303. A Stroke of Error | PSNet
      psnet.ahrq.gov/web-mm/stroke-error
      February 01, 2016 - Instructions Scale Definition Score 1a.

1304. Psn-Pdf (pdf file)
      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…

1305. Right Patient, Wrong Sample | PSNet
      psnet.ahrq.gov/web-mm/right-patient-wrong-sample
      June 01, 2004 - Right Patient, Wrong Sample Citation Text: Astion ML. Right Patient, Wrong Sample. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…

1306. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866055/psn-pdf
      May 29, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle May 29, 2024 https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle Summary Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common catego…

1307. The Role of the Patient in Improving Patient Safety | PSNet
      psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
      March 01, 2007 - The Role of the Patient in Improving Patient Safety Rosemary Gibson, MSc | March 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. Rockville…

1308. Crossing the Line | PSNet
      psnet.ahrq.gov/web-mm/crossing-line
      December 01, 2012 - SPOTLIGHT CASE Crossing the Line Citation Text: Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…

1309. The Missing Abscess: Radiology Reads in the Digital Era | PSNet
      psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
      January 01, 2009 - SPOTLIGHT CASE The Missing Abscess: Radiology Reads in the Digital Era Citation Text: Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation…

1310. EMR Entry Error: Not So Benign | PSNet
      psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
      July 01, 2012 - EMR Entry Error: Not So Benign Citation Text: Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

1311. Novel Drug Misuse | PSNet
      psnet.ahrq.gov/web-mm/novel-drug-misuse
      September 30, 2010 - SPOTLIGHT CASE Novel Drug Misuse Citation Text: Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

1312. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures | PSNet
      psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
      November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures Citation Text: Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …

1313. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest | PSNet
      psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
      February 01, 2023 - SPOTLIGHT CASE When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Citation Text: Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…

1314. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73642/psn-pdf
      August 25, 2021 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected August 25, 2021 Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect- unexpected …

1315. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49648/psn-pdf
      March 01, 2012 - Postdischarge Follow-Up Phone Call March 1, 2012 Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call Case Objectives Understand why preventing readmissions through postdischarge phone calls is important. Describe evidence su…

1316. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
      January 01, 2022 - Spotlight Spotlight Delayed Diagnosis of Mesenteric Ischemia Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc o AHRQ WebM&M…

1317. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49454/psn-pdf
      July 01, 2004 - Novel Drug Misuse July 1, 2004 Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/novel-drug-misuse Case Objectives Define the inclusion and exclusion criteria for patients in PROWESS. Understand why the FDA included APACHE score as an indication criterion for drotrec…

1318. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49527/psn-pdf
      December 01, 2006 - Right Patient, Wrong Sample December 1, 2006 Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample The Case A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On the morning of surgery, the patien…

1319. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33740/psn-pdf
      November 01, 2012 - In Conversation With… Abraham Verghese, MD November 1, 2012 In Conversation With… Abraham Verghese, MD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-abraham-verghese-md Editor's note: Abraham Verghese, MD, is Professor for the Theory and Practice of Medicine at the Stanford University S…

1320. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49624/psn-pdf
      May 01, 2011 - Duty to Disclose Someone Else's Error? May 1, 2011 Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error Case Objectives State the rationale for disclosing medical errors. Describe key principles in effective error disclosure. …