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  1. psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
    October 01, 2017 - Preventing PICC Complications: Whose Line Is It? Citation Text: Moureau N. Preventing PICC Complications: Whose Line Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibT…
  2. psnet.ahrq.gov/web-mm/dont-push
    March 02, 2011 - Don't Push Citation Text: Meltzer HY. Don't Push. 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 tagged PubMedId RIS Downl…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49630/psn-pdf
    July 01, 2011 - Watch the Warfarin! July 1, 2011 Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/watch-warfarin Case Objectives Understand best practices for safe discharge of patients on warfarin. Describe recent advances in anticoagulation monitoring for ambulatory patients. Discu…
  4. psnet.ahrq.gov/web-mm/chemotherapy-extravasation
    September 24, 2010 - Chemotherapy Extravasation Citation Text: Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
  5. Psn-Pdf (pdf file)

    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…
  6. psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
    March 21, 2009 - A Mistaken Dose of Naloxone  Citation Text: Cutler E, Gunawardena D. A Mistaken Dose of Naloxone . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  7. psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
    September 01, 2012 - Add-on Case and the Missing Checklist Citation Text: Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49754/psn-pdf
    February 01, 2016 - Picking Up the Cause of the Stroke February 1, 2016 Chopra V. Picking Up the Cause of the Stroke. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/picking-cause-stroke The Case A 62-year-old man with poorly controlled diabetes was transferred to a tertiary care center from a community hospital for management…
  9. psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
    August 05, 2009 - Discharge Instructions in the PACU: Who Remembers? Citation Text: Engel KG. Discharge Instructions in the PACU: Who Remembers?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar B…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867428/psn-pdf
    December 18, 2024 - When it came to decision support for osteoporosis, we looked in the system for a diagnosis of osteoporosis … If the patient had either of those diagnoses and did not have a prescription for a bone- strengthening
  11. psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
    May 01, 2008 - Many of the early interventions with computers and medicine were focused on getting better diagnoses, … July 24, 2024 Documenting Diagnosis: Exploring the Impact of Electronic Health Records
  12. psnet.ahrq.gov/web-mm/communication-consultants
    October 01, 2018 - The following day, the hematologist confirmed the diagnosis of leukostasis as the result of acute myeloid … A consultation is a formal request made from one provider to another to give their opinion on the diagnosis … The requesting clinician may seek consultation for any number of reasons ranging from advice on diagnosis … Quality April 26, 2023 WebM&M Cases Delayed Diagnosis … 23, 2022 WebM&M Cases Missing ECG and Missed Diagnosis
  13. psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
    August 01, 2006 - In this scenario, one set of orders was written at the time of diagnosis and another, with adjusted doses … May 1, 2005 WebM&M Cases Delayed Breast Cancer Diagnosis … January 6, 2017 Process of care failures in breast cancer diagnosis.
  14. psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
    June 01, 2017 - We looked at 4 million emergency admissions in the United Kingdom, and we looked at 50 different diagnosis … We adjusted for age, sex, economic deprivation, comorbidities, and the admitting diagnosis. … of all nonfederal United States hospitals), compared outcomes of patients admitted with a principal diagnosis
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836941/psn-pdf
    April 27, 2022 - underemphasized, area of concern in home-based primary care is diagnostic error, including missed diagnosis … , delayed diagnosis, and wrong diagnoses.7 While this has been shown to be problematic in office-based … Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians
  16. psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
    April 24, 2024 - but underemphasized, area of concern in home-based primary care is diagnostic error, including missed diagnosis … , delayed diagnosis, and wrong diagnoses. 7 While this has been shown to be problematic in office-based … Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians
  17. psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
    January 01, 2014 - Examination of the bowel showed Aspergillus, leading to a diagnosis of disseminated aspergillosis.
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49684/psn-pdf
    May 01, 2013 - In this scenario, one set of orders was written at the time of diagnosis and another, with adjusted
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49708/psn-pdf
    May 01, 2014 - admitted to the hospital with abdominal pain and diagnosed with a bowel obstruction, secondary to a new diagnosis
  20. psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
    June 01, 2017 - of all nonfederal United States hospitals), compared outcomes of patients admitted with a principal diagnosis … We looked at 4 million emergency admissions in the United Kingdom, and we looked at 50 different diagnosis … We adjusted for age, sex, economic deprivation, comorbidities, and the admitting diagnosis.

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