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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.
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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.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downl…
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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…
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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.
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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/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.
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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.
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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…
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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.
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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
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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
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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
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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.
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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
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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
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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
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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.
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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
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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
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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.