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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/node/49679/psn-pdf
March 01, 2013 - The Unfamiliar Catheter
March 1, 2013
Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/unfamiliar-catheter
The Case
A 28-year-old woman, 20 months post–bilateral lung transplant, presented to the emergency department
with sudden onset of severe shortness of breath…
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psnet.ahrq.gov/web-mm/discharge-against-medical-advice
July 01, 2017 - Discharge Against Medical Advice
Citation Text:
Hwang SW. Discharge Against Medical Advice. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - One Bronchoscopy, Two Errors
Citation Text:
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. 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 XM…
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - January 22, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/sites/default/files/2020-04/spotlight-slides-wright-schiff.pdf
January 01, 2020 - Spotlight
The Lost Start Date, an Unknown
Risk of E-prescribing
Source and Credits
• This presentation is based on the October 2019
AHRQ WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Adam Wright, PhD, and Gordon
Schiff, MD
○ Editor, AHRQ…
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psnet.ahrq.gov/node/49445/psn-pdf
May 01, 2004 - No Blood, Please
May 1, 2004
Liang BA. No Blood, Please. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/no-blood-please
The Case
A young woman, about 30 years of age, was injured in an automobile collision. She was brought to the
emergency department (ED) via ambulance, where she was found to be suffering …
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psnet.ahrq.gov/node/33592/psn-pdf
December 15, 2024 - Adverse Events, Near Misses, and Errors
December 15, 2024
Adverse Events, Near Misses, and Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current re…
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psnet.ahrq.gov/node/33573/psn-pdf
March 15, 2025 - Disruptive and Unprofessional Behavior
March 15, 2025
Disruptive and Unprofessional Behavior. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current resear…
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psnet.ahrq.gov/node/867429/psn-pdf
December 18, 2024 - durotomies using various materials as well as
postoperative CSF leak management strategies will be discussed
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psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
May 28, 2020 - KH: Is there anything we haven’t discussed that you think the patient safety community may want to hear
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psnet.ahrq.gov/node/853774/psn-pdf
September 27, 2023 - A previous PSNet Commentary addressing
delayed diagnosis of a ruptured aortic aneurysm discussed the
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psnet.ahrq.gov/node/865454/psn-pdf
March 27, 2024 - Several studies this year discussed factors that were associated with decreased stress and burnout.
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - have a financial arrangement or other relationship with the manufacturers of any commercial products discussed
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psnet.ahrq.gov/web-mm/dependence-vs-pain
October 30, 2019 - has a financial arrangement or other relationship with the manufacturers of any commercial products discussed
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - have a financial arrangement or other relationship with the manufacturers of any commercial products discussed
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - associated with sepsis, which continues to be the leading cause of inpatient hospital deaths. 11 As discussed
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - has a financial arrangement or other relationship with the manufacturers of any commercial products discussed
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - have
a financial arrangement or other relationship with the manufacturers of any commercial products discussed
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - As an alternative to
admission, the physician discussed the case with a cardiologist who recommended