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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - Systems Engineering Initiative for Patient Safety (SEIPS) model of work systems and patient safety ( 5 ) describes
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psnet.ahrq.gov/web-mm/breakage-picc-line
June 21, 2023 - placement of PICCs may be related to an increased risk of complications.( 8 ) The case presented here describes
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psnet.ahrq.gov/node/843151/psn-pdf
February 01, 2023 - Cisgender describes people who are not transgender and whose gender is aligned with the sex assigned
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psnet.ahrq.gov/node/49859/psn-pdf
April 01, 2019 - In summary, this case describes a serious injury due to use of an e-cigarette, a known ignition source
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psnet.ahrq.gov/web-mm/emergency-error
January 18, 2013 - up around 50% of the general surgery workload but accounts for 80%–90% of all deaths.( 1 ) This case describes
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Boe, MD
This case describes a 31-year-old pregnant patient with type 1 diabetes on an insulin pump who
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Boe, MD
8
BACKGROUND
9
Background (1)
• This case describes a 31-year-old pregnant patient with
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psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
September 15, 2024 - Summary This primer describes stressors relevant to the healthcare response to the COVID-19 pandemic
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psnet.ahrq.gov/curated-library/artificial-intelligence-system-level-considerations
March 27, 2024 - This article summarizes the history and evolution of AI in healthcare and describes current applications
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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - The following discussion describes types of post-discharge adverse events, their epidemiology, important
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - The Commentary
by Lucy Shi, MD and Erik Noren MD, MS
This case describes a patient who developed
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens
Citation Text:
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/issue/patient-engagement-patient-safety-why-what-and-how-patient-engagement-improving-patient
July 15, 2020 - psnet
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - The Commentary By Noelle Boctor, MD, and Mithu Molla, MD, MBA This case describes a 63-year-old man with
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psnet.ahrq.gov/node/866370/psn-pdf
July 31, 2024 - The patient in this Case describes the sensation of not receiving
adequate ventilation while she was
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psnet.ahrq.gov/perspective/conversation-susan-smith-md
August 01, 2019 - He describes the policies that we have for scribes and documents that both the scribe and the physician
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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/node/33701/psn-pdf
October 01, 2010 - What Makes a Good Checklist
October 1, 2010
McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/what-makes-good-checklist
Perspective
The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex
tasks. Checklists have lo…
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psnet.ahrq.gov/node/49465/psn-pdf
December 22, 2021 - Electronic Err
October 1, 2004
Tang PC. Electronic Err. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/electronic-err
The Case
A 75-year-old woman with coronary artery disease presented to the emergency department (ED) with chest
pain that that had not responded to three sublingual nitroglycerin tablets at…
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psnet.ahrq.gov/node/49836/psn-pdf
July 01, 2018 - Primary Workaround, Secondary Complication
July 1, 2018
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
The Case
A young adult with a progressive neurological disorder presented to a hospital emerg…