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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - misdiagnosis-related harms for major vascular events, infections, and cancers: toward a national incidence estimate
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psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - reduced, UCSF's Internal Medicine residency program experienced a 40% increase in signouts.( 1 ) We estimate
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psnet.ahrq.gov/node/38400/psn-pdf
February 11, 2009 - The impact of clinically undiagnosed injuries on survival
estimates.
February 11, 2009
Gedeborg R, Thiblin I, Byberg L, et al. The impact of clinically undiagnosed injuries on survival estimates.
Crit Care Med. 2009;37(2). doi:10.1097/ccm.0b013e318194b164.
https://psnet.ahrq.gov/issue/impact-clinically-undiagnosed…
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psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
March 27, 2024 - In that case, there is not a lot of clinical value from that estimate. … these models work for segments of the population and how much trust can we put into a model for its estimate
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psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
March 27, 2024 - In that case, there is not a lot of clinical value from that estimate. … these models work for segments of the population and how much trust can we put into a model for its estimate
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psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
January 01, 2014 - In Conversation With… Hardeep Singh, MD, MPH
December 1, 2013
Also Read an Essay
Also Read an Essay
Citation Text:
In Conversation With… Hardeep Singh, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Heal…
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psnet.ahrq.gov/node/48175/psn-pdf
August 07, 2019 - Strengthening the medical error "meme pool."
August 7, 2019
Mazer BL, Nabhan C. Strengthening the Medical Error "Meme Pool". J Gen Intern Med. 2019;34(10):2264-
2267. doi:10.1007/s11606-019-05156-7.
https://psnet.ahrq.gov/issue/strengthening-medical-error-meme-pool
Published estimates on the number preventable med…
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psnet.ahrq.gov/node/47178/psn-pdf
July 10, 2018 - Defining, estimating, and communicating overdiagnosis
in cancer screening.
July 10, 2018
Davies L, Petitti DB, Martin L, et al. Defining, estimating, and communicating overdiagnosis in cancer
screening. Ann Intern Med. 2018;169(1):36-43. doi:10.7326/M18-0694.
https://psnet.ahrq.gov/issue/defining-estimating-and-co…
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psnet.ahrq.gov/node/49766/psn-pdf
August 21, 2016 - Getting the (Right) Doctor, Right Away
August 21, 2016
Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
The Case
A 57-year-old woman with a history of chronic obstructive pulmonary disease underwent hip surgery.
Postop…
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psnet.ahrq.gov/node/49767/psn-pdf
August 21, 2016 - Falling Between the Cracks in the Software
August 21, 2016
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-between-cracks-software
The Case
A 61-year-old man with a history of osteoarthritis was scheduled for a total knee replacement. Prio…
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psnet.ahrq.gov/node/49658/psn-pdf
July 01, 2012 - Misleading Complaint
July 1, 2012
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/misleading-complaint
The Case
A 54-year-old homeless man with a history of alcoholism presented to the emergency department (ED) with
complaints of knee problems. The triage nurse docu…
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psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
November 01, 2023 - Inadvertent Use of More Potent Acid Leads to Burn
Citation Text:
Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar B…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
December 01, 2014 - PowerPoint Presentation
Spotlight
A Stroke of Error
This presentation is based on the December 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Kevin M. Barrett, MD, MSc, Consultant, Associate Professor of Neurology, Director, Neurohospitalist F…
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psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
December 15, 2024 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events
Citation Text:
Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Cit…
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psnet.ahrq.gov/node/50699/psn-pdf
November 26, 2019 - Patient Safety in Frail Older Patients
November 26, 2019
Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
Background
Older patients are at a particular risk of experiencing a patient safety event. Stud…
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psnet.ahrq.gov/sites/default/files/2020-04/final_april-spotlight-implicit_biases_04.02.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Implicit Biases, Interprofessional
Communication, and Power
Dynamics
Source and Credits
• This presentation is based on the April 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Erin Stephany Sanchez, MD, Melody Tran-
Reina, MD, Kupi…
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psnet.ahrq.gov/web-mm/ebola-are-we-ready
July 01, 2012 - Ebola: Are We Ready?
Citation Text:
Barsuk JH, Barnard C. Ebola: Are We Ready?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx
Spotlight
Overdose of Gabapentin and Oxycodone in a Patient
with End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotli…
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psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride
May 27, 2020
Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
The Case
An infant with trisomy 21 underwent repair of a…
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psnet.ahrq.gov/node/49564/psn-pdf
July 01, 2008 - Dependence vs. Pain
July 1, 2008
Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/dependence-vs-pain
Case Objectives
Define opioid dependence and opioid withdrawal syndrome.
Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid
Withdra…