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psnet.ahrq.gov/web-mm/snfs-opening-black-box
August 27, 2012 - SNFs: Opening the Black Box
Citation Text:
Ouslander JG, Bonner A. SNFs: Opening the Black Box. 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/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - SPOTLIGHT CASE
Unexplained Apnea Under Anesthesia
Citation Text:
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - SPOTLIGHT CASE
A Painful Medication Reconciliation Mishap
Citation Text:
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/49618/psn-pdf
February 01, 2011 - One Toxic Drug Is Not Like Another
February 1, 2011
Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
Case Objectives
Distinguish between the three distinct regulatory processes of board certification, medical licensure,
and credential…
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
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psnet.ahrq.gov/node/33720/psn-pdf
November 01, 2011 - In Conversation With… Eduardo Salas, PhD
November 1, 2011
In Conversation With… Eduardo Salas, PhD . PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
Editor's note: Eduardo Salas, PhD, is a University Trustee Chair and Pegasus Professor of Psychology at
the University of Ce…
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psnet.ahrq.gov/node/49744/psn-pdf
October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced
Hemolysis in a Patient With a Known Allergy
October 1, 2015
Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known
Allergy. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - SPOTLIGHT CASE
A Weighty Mistake
Citation Text:
Bokser SJ. A Weighty Mistake. 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/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy
Citation Text:
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
November 16, 2022 - Technology now has a prominent role in many aspects of healthcare delivery including admissions, discharge, diagnosis … used HFE methods and principles to create a clinical decision support (CDS) for pulmonary embolism diagnosis … Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - The diagnosis of Cushing syndrome was considered, and subsequent testing for this syndrome was positive
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psnet.ahrq.gov/node/836976/psn-pdf
April 27, 2022 - Compartment syndrome is a clinical diagnosis and patients’ reported symptoms are the earliest indicators … like that
used in pulse oximetry, has been proposed as an objective and non-invasive tool for the diagnosis … tool to monitor for compartment syndrome.30 As in adults, compartment syndrome remains a
clinical diagnosis … Compartment syndrome is a clinical diagnosis. … Acute compartment syndrome in children: contemporary
diagnosis, treatment, and outcome.
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psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
May 01, 2016 - April 8, 2011
Antecedent treat-and-release diagnoses prior to sepsis hospitalization
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psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
December 14, 2022 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
July 01, 2006 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
March 22, 2009 - health literacy has been repeatedly linked to problems with the use of preventive services, delayed diagnoses
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psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
October 01, 2007 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
December 14, 2022 - Patient Safety Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
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psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
March 01, 2009 - health literacy has been repeatedly linked to problems with the use of preventive services, delayed diagnoses