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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - Crushing Chest Pain: A Missed Opportunity
January 1, 2004
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
Case Objectives
Appreciate the challenges of diagnosing aortic dissection
Describe a Bayesian approach to dia…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
September 27, 2023 - SPOTLIGHT CASE
Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation
Citation Text:
Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation. PSNet [internet]. Rockville (MD): Agency for Health…
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psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
September 09, 2013 - SPOTLIGHT CASE
Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care
Citation Text:
Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/node/863649/psn-pdf
February 28, 2024 - In Conversation With...Stephen Hines, PhD and Monika
Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS
3.0
February 28, 2024
In Conversation With..Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about
TeamSTEPPS 3.0. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withstephen-…
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near-
Miss Wrong Transfusion Event
January 29, 2020
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
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psnet.ahrq.gov/node/49611/psn-pdf
October 01, 2010 - The Deadly Duo
October 1, 2010
Maldonado JR. The Deadly Duo. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/deadly-duo
The Case
A 29-year-old man with a history of depression and possible psychosis was found unconscious and
unresponsive at home and was brought to the emergency department. He was tachycardi…
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - Delayed Diagnosis of Mesenteric Ischemia
August 31, 2022
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for…
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - Syringe Swap During Regional Block: A Case of
Medication Error and Recovery
January 31, 2024
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…
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psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
March 01, 2005 - SPOTLIGHT CASE
CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure
Citation Text:
Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…
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psnet.ahrq.gov/node/33759/psn-pdf
October 01, 2012 - Promising Areas for Patient Safety Research
December 1, 2003
Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. PSNet [internet]. 2003.
https://psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
Perspective
Setting a Course for Patient Safety Research
Although patient safety…
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psnet.ahrq.gov/node/33706/psn-pdf
February 01, 2011 - In Conversation with...Brent C. James, MD, MStat
February 1, 2011
In Conversation with..Brent C. James, MD, MStat. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
Editor's note: Brent C. James, MD, MStat, is Chief Quality Officer and Executive Director of the Insti…
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psnet.ahrq.gov/curated-library/diagnostic-safety-improvement
July 21, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Diagnostic Safety Improvement
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNe…
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - SPOTLIGHT CASE
Crushing Chest Pain: A Missed Opportunity
Citation Text:
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google …
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psnet.ahrq.gov/print/pdf/node/838351
July 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Diagnostic Safety Improvement
Curated Library
Foundations
Improving Diagnosis in Health Care.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and
Medicine. Washington, DC: National Academies Press; …
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psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
July 21, 2020 - SPOTLIGHT CASE
Anemia and Delayed Colon Cancer Diagnosis
Citation Text:
Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format: …
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psnet.ahrq.gov/print/pdf/node/866100
August 30, 2023 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Nurse Wellbeing and Patient Safety
Curated Library
Foundations
Keeping Patients Safe: Transforming the Work Environment of Nurses.
Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care
Services. Wash…
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psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - SPOTLIGHT CASE
Triple Handoff
Citation Text:
Vidyarthi A. Triple Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - SPOTLIGHT CASE
Delayed Diagnosis of Mesenteric Ischemia
Citation Text:
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
Copy Citation
Format:
…
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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO
January 12, 2022
Also Read the Essay
Citation Text:
In Conversation With.…
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psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things Changed?
Helen Haskell, MA | June 1, 2014
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed?. PSNet [internet]. Ro…