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  1. psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
    January 29, 2021 - SPOTLIGHT CASE A Missed Bowel Perforation - the Importance of Diagnostic Reasoning Citation Text: Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853902/psn-pdf
    September 27, 2023 - A Missed Bowel Perforation - the Importance of Diagnostic Reasoning September 27, 2023 Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning Disclosure of …
  3. psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
    July 30, 2020 - Coronavirus Disease 2019 (COVID-19) and Diagnostic Error Citation Text: Desai AN, Romano PS. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867004/psn-pdf
    October 30, 2024 - Critical Radiology Alert Process October 30, 2024 https://psnet.ahrq.gov/innovation/critical-radiology-alert-process Summary Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of unrelated abnormal findings and provides a companion follow-up process, with the goal o…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33595/psn-pdf
    December 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety December 15, 2024 Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that th…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49524/psn-pdf
    November 01, 2006 - Secured But Not Always Safe November 1, 2006 Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/secured-not-always-safe The Case An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative osteoarthritis. She received spinal …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49412/psn-pdf
    September 01, 2003 - Shake Well September 1, 2003 Flynn EA. Shake Well. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/shake-well The Case A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily serum drug levels consistently fell below the therapeutic range, which led the physi…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33641/psn-pdf
    November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again November 1, 2006 Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again Perspective Certain phrases ar…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49743/psn-pdf
    September 01, 2015 - Dual Therapy Debacle September 1, 2015 Kayser SR. Dual Therapy Debacle. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/dual-therapy-debacle The Case An elderly man with a history of arthritis, benign prostatic hypertrophy with urinary obstruction, hyperlipidemia, obesity, and a long history of tobacco use …
  10. psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - • When the IR team evaluated the patient on day 65, they re-reviewed the CT scan from 24 days earlier
  11. psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
    January 29, 2021 - medication The effect of midazolam or dexmedetomidine given for preoperative anxiolysis should be carefully evaluated
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73953/psn-pdf
    October 27, 2021 - Deprescribing as a Patient Safety Strategy October 27, 2021 Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy Background Polypharmacy is defined as the act of taking five or more medications on a regular basis…
  13. psnet.ahrq.gov/web-mm/managing-care-challenges-group-home-setting-staffing-adequate-unplanned-incidents
    April 27, 2022 - Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents? Citation Text: Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
  14. psnet.ahrq.gov/web-mm/dressed-failure
    September 01, 2011 - DRESSed for Failure Citation Text: Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
  15. psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
    May 01, 2017 - Wrong Turn through Colon: Misplaced PEG Citation Text: Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. 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…
  16. psnet.ahrq.gov/web-mm/medical-devices-wild
    March 27, 2024 - Medical Devices in the "Wild" Citation Text: Gurses AP, Doyle PA. Medical Devices in the "Wild". 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 …
  17. psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
    January 31, 2020 - Annual Perspective Updates in the Role of Health IT in Patient Safety February 21, 2020  View more articles from the same authors. Citation Text: Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. Rockville …
  18. 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…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49677/psn-pdf
    February 01, 2013 - CVC Placement: Speak Now or Do Not Use the Line February 1, 2013 Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line The Case A 48-year-old woman with a history of hypertension, psychiatric illness, and a…
  20. psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
    June 07, 2023 - Breathe Easy: Safe Tracheostomy Management Citation Text: Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar Bib…

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