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  1. psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defining-clinical-reasoning
    June 26, 2019 - Commentary Emerging Classic Drawing boundaries: the difficulty in defining clinical reasoning. Citation Text: Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning. Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0…
  2. psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classification-and-consequences
    June 21, 2016 - Study Classic Cognitive errors in diagnosis: instantiation, classification, and consequences. Citation Text: Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation, classification, and consequences. Am J Med. 1989;86(4):433-41. Copy Citation …
  3. psnet.ahrq.gov/issue/communication-about-medical-errors
    December 16, 2020 - Commentary Communication about medical errors. Citation Text: Kaldjian LC. Communication about medical errors. Patient Educ Couns. 2021;104(5):989-993. doi:10.1016/j.pec.2020.11.035. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
  4. psnet.ahrq.gov/issue/conceptualising-learning-resilient-performance-scoping-literature-review
    October 09, 2024 - Review Conceptualising learning from resilient performance: a scoping literature review. Citation Text: Degerman H, Wallo A. Conceptualising learning from resilient performance: a scoping literature review. Appl Ergon. 2024;115:104165. doi:10.1016/j.apergo.2023.104165. Copy Citation …
  5. psnet.ahrq.gov/issue/blaming-learning-re-framing-organisational-learning-adverse-incidents
    October 05, 2022 - Study From blaming to learning: re-framing organisational learning from adverse incidents. Citation Text: Gray D, Williams S. From blaming to learning: re‐framing organisational learning from adverse incidents. Learn Org. 2011;18(6):438-453. doi:10.1108/09696471111171295. Copy Citatio…
  6. psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
    January 01, 2016 - Charcoal Lavage of the Lungs Citation Text: Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49730/psn-pdf
    April 01, 2015 - Transition to Nowhere April 1, 2015 Farrell TW. Transition to Nowhere. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/transition-nowhere The Case A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension, and chronic kidney disease was admitted to the hospital …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33631/psn-pdf
    April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety April 1, 2006 Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49656/psn-pdf
    June 01, 2012 - Comanagement: Who's in Charge? June 1, 2012 Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/comanagement-whos-charge The Case A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left hip fracture to the orthopedic surg…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49514/psn-pdf
    July 01, 2006 - One ACE Too Many July 1, 2006 Juurlink DN. One ACE Too Many. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/one-ace-too-many The Case A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure presented to the emergency department (ED) with chest pain. An acut…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33815/psn-pdf
    September 01, 2016 - Telemedicine and Patient Safety September 1, 2016 Agboola SO, Kvedar JC. Telemedicine and Patient Safety. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/telemedicine-and-patient-safety Perspective A paradigm shift is ongoing in the health care sector. The traditional model of episodic and hospital-base…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49420/psn-pdf
    October 01, 2003 - To LP or Not LP October 1, 2003 Landrigan CP. To LP or Not LP. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lp-or-not-lp The Case A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with fever and irritability without an obvious source. He was referred to …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60169/psn-pdf
    March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room. March 25, 2020 Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49577/psn-pdf
    January 01, 2009 - Are Two Insulin Pumps Better Than One? January 1, 2009 Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one The Case A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass graft surge…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49477/psn-pdf
    April 01, 2005 - Hold the tPA April 1, 2005 Fagan SC. Hold the tPA. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/hold-tpa The Case A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49390/psn-pdf
    February 01, 2003 - Flying Object Hits MRI February 1, 2003 Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/flying-object-hits-mri The Case A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an anesthesiologist, the child was receiving…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49387/psn-pdf
    February 01, 2003 - Patient Mix-Up February 1, 2003 Shojania KG. Patient Mix-Up. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/patient-mix The Case Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general medical service at an academic medical center. Overnight, another man wit…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33681/psn-pdf
    March 01, 2009 - The Role of Health Literacy in Patient Safety March 1, 2009 Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/role-health-literacy-patient-safety Perspective Clear health communication is increasingly recognized as essential for promoting …
  19. psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
    December 22, 2018 - Annual Perspective Burnout Among Health Professionals and Its Effect on Patient Safety Audrey Lyndon, PhD | January 1, 2015  View more articles from the same authors. Citation Text: Lyndon A. Burnout Among Health Professionals and Its Effect on Patient Safety…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33602/psn-pdf
    March 15, 2025 - Individual Clinician Performance Issues March 15, 2025 Individual Clinician Performance Issues. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/individual-clinician-performance-issues PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current res…

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