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  1. Getting the Diagnosis Both Right and Wrong | PSNet

    psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
    May 29, 2024 - Getting the Diagnosis Both Right and Wrong Citation Text: Olson AP. Getting the Diagnosis Both Right and Wrong. 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…

  2. Double Trouble | PSNet

    psnet.ahrq.gov/web-mm/double-trouble
    August 01, 2012 - SPOTLIGHT CASE Double Trouble Citation Text: Gurwitz JH. Double Trouble. 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 Endnote t…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49531/psn-pdf
    March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857259/psn-pdf
    November 30, 2023 - Medication Mix-Up Leads to Patient Death November 30, 2023 Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death The Case  An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49829/psn-pdf
    May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…

  6. One Dose, Two Errors | PSNet

    psnet.ahrq.gov/web-mm/one-dose-two-errors
    September 29, 2017 - One Dose, Two Errors Citation Text: Filice GA. One Dose, Two Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33703/psn-pdf
    November 01, 2010 - Are We Getting Better at Measuring Patient Safety? November 1, 2010 Rosen AK. Are We Getting Better at Measuring Patient Safety? PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety Perspective The past decade has witnessed unprecedented interest in patient safe…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866205/psn-pdf
    July 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. July 10, 2024 Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hemorrhagic-sh…

  9. Tacit Handover, Overt Mishap | PSNet

    psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
    August 01, 2006 - Tacit Handover, Overt Mishap Citation Text: Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865656/psn-pdf
    April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous Combination April 24, 2024 Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination The Case A 26-ye…

  11. Diagnosing a Missed Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
    October 26, 2022 - Diagnosing a Missed Diagnosis Citation Text: Reilly JB, Webster C. Diagnosing a Missed Diagnosis. 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 EndNote 7…

  12. Procedure Complications – Who is Responsible for Follow up? | PSNet

    psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
    July 31, 2023 - Procedure Complications – Who is Responsible for Follow up? Citation Text: Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Cita…

  13. Language Barrier | PSNet

    psnet.ahrq.gov/web-mm/language-barrier
    February 28, 2024 - Language Barrier Citation Text: Flores G. Language Barrier. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49570/psn-pdf
    October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure? October 1, 2008 Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure Case Objectives Understand the complementary abilities of an electronic health record a…

  15. Empty Handoff | PSNet

    psnet.ahrq.gov/web-mm/empty-handoff
    August 01, 2017 - Empty Handoff Citation Text: Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

  16. Harm From Alarm Fatigue | PSNet

    psnet.ahrq.gov/web-mm/harm-alarm-fatigue
    February 14, 2018 - SPOTLIGHT CASE Harm From Alarm Fatigue Citation Text: Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837659/psn-pdf
    July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging July 8, 2022 Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging The Cases Case #1: A 42-year-old woman admitted with…

  18. Picking Up the Cause of the Stroke | PSNet

    psnet.ahrq.gov/web-mm/picking-cause-stroke
    August 07, 2024 - Picking Up the Cause of the Stroke Citation Text: Chopra V. Picking Up the Cause of the Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33767/psn-pdf
    May 01, 2014 - Innovations in Promoting Hand Hygiene Compliance May 1, 2014 Marra AR, Edmond MB. Innovations in Promoting Hand Hygiene Compliance. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance Perspective One hundred sixty-five years after the publication of Ignaz Semmel…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33702/psn-pdf
    November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH November 1, 2010 In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…
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