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psnet.ahrq.gov/node/73300/psn-pdf
July 01, 2022 - The checklist can be
integrated into the electronic health record or a form can be provided to the patient
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psnet.ahrq.gov/node/49833/psn-pdf
June 01, 2018 - Perils in Diagnosing a Stroke
June 1, 2018
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
The Case
A 75-year-old man with a history of hypertension, diabetes, chronic back pain, and opioid use disorder was
brought to the emergency depart…
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psnet.ahrq.gov/node/33804/psn-pdf
March 03, 2016 - And now nearly everybody has electronic health records, which was not true at the start of this
program
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psnet.ahrq.gov/node/49591/psn-pdf
October 01, 2009 - Difficult Encounters: A CMO and CNO Respond
October 1, 2009
Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
Case Objectives
Appreciate the risk of disruptive behavior and understand institutional respons…
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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - Advancing Patient Safety Through State Reporting
Systems
June 1, 2007
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
Perspective
Seven years ago, the Institute of Medicine (I…
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - Care Transitions
Sunil Kripalani, MD, MSc | December 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Kripalani S. Care Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depart…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination
August 31, 2022 - Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination
Citation Text:
Valdes W, Utter GH. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Hea…
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - In Conversation with...Eric Coleman, MD, MPH
December 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Eric Coleman, MD, MPH. PSNet [internet]. 2007.In Conversation with...Eric Coleman, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthca…
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psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - The Wrong Shot: Error Disclosure
June 1, 2004
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
Case Objectives
Describe the rationale for disclosing harmful errors to patients.
Describe the specific information that patie…
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psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
September 23, 2024 - quantity of data collected, missing data, lack of clinical decision support, and inability to customize electronic … health record [EHR] dashboards.
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - For instance, investment in enhancements of the electronic medical record could assist in improving physician
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - appropriately broad differential diagnosis, as their thought process was incompletely documented in the
electronic … health record (EHR).
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psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
March 01, 2017 - April 1, 2018
Perspective
Assessing the Safety of Electronic … Health Records: What Have We Learned?
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citation
Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again
John Gosbee, MD, MS | November 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Aga…
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psnet.ahrq.gov/web-mm/time-death
January 03, 2017 - January 23, 2013
Development of a tool within the electronic medical record to facilitate
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - In Conversation With...Donald A. Norman, PhD
November 1, 2006
Also Read an Essay
Citation Text:
In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006.In Conversation With...Donald A. Norman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthca…
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psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
March 24, 2019 - WebM&M Cases
Weight and Height Juxtaposition in the Electronic … Medical Record Causing an Accidental Medication Overdose
October 31, 2023
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - The Result Stopped Here
June 1, 2004
Astion ML. The Result Stopped Here. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/result-stopped-here
The Case
A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital
for continued wound care and intravenous (IV) antib…
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psnet.ahrq.gov/node/49461/psn-pdf
September 01, 2004 - Reaction to Dye
September 1, 2004
Cohan R. Reaction to Dye. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/reaction-dye
The Case
A patient was referred to urology after having several episodes of gross hematuria. The urologist thought
that the patient might have a renal mass and sent him to radiology for a…