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  1. psnet.ahrq.gov/issue/translating-electronic-health-record-based-patient-safety-algorithms-research-clinical
    October 27, 2021 - Study Translating electronic health record-based patient safety algorithms from research to clinical practice at multiple sites. Citation Text: Translating electronic health record-based patient safety algorithms from research to clinical practice at multiple sites. Zimolzak AJ, Singh H,…
  2. psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
    January 01, 2016 - Some experts have criticized the practice of evaluating errors in hindsight, but we maintain that systematic
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49824/psn-pdf
    March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay March 1, 2018 O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay The Case A 35-year-old woman with no prior cardiac history calle…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50931/psn-pdf
    February 26, 2020 - Timely diagnosis of esophageal perforation February 26, 2020 Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation The Case  A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49773/psn-pdf
    July 01, 2016 - Near Miss With Neonate October 1, 2016 Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/near-miss-neonate The Case A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm dates. Early the next morning, intravenous oxy…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49448/psn-pdf
    June 01, 2004 - Listen to the Family June 1, 2004 Campbell D. Listen to the Family. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/listen-family The Case Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The surgical resident examined the patient, an elderly woman with …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49439/psn-pdf
    March 01, 2004 - Lethal Cap March 1, 2004 Schillinger D. Lethal Cap. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-cap The Case A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
    November 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfusion Overload 1 2 Source and Credits This presentation is based on the November 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Manish S. Patel, MD, and Jeffrey L. Carson, MD, of UMDNJ−Robert Wood …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49730/psn-pdf
    April 01, 2015 - Transition to Nowhere April 1, 2015 Farrell TW. Transition to Nowhere. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/transition-nowhere The Case A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension, and chronic kidney disease was admitted to the hospital …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33631/psn-pdf
    April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety April 1, 2006 Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49781/psn-pdf
    January 01, 2017 - Hazards of Loading Doses January 1, 2017 Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hazards-loading-doses The Case A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac arrest. Two days after discharg…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49520/psn-pdf
    September 01, 2006 - DNR in the OR and Afterwards September 1, 2006 Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards The Case An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and suffered a fractured femur. After initial eval…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33615/psn-pdf
    June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD June 1, 2005 In Conversation with…Peter J. Pronovost, MD, PhD. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd Editor's Note: Peter J. Pronovost, MD, PhD, is Medical Director of the Johns Hopkins Center for Innova…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866265/psn-pdf
    July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport July 31, 2024 MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33858/psn-pdf
    May 01, 2018 - In Conversation With… John Halamka, MD, MS May 1, 2018 In Conversation With… John Halamka, MD, MS. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms Editor's note: Dr. Halamka is the International Healthcare Innovation Professor at Harvard Medical School, Chief Information …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866370/psn-pdf
    July 31, 2024 - Intraoperative Awareness during Rhinoplasty July 31, 2024 Bohringer C, Toor J. Intraoperative Awareness during Rhinoplasty. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation …
  17. psnet.ahrq.gov/issue/more-feeling-role-empathetic-care-promoting-safety-health-care
    June 23, 2021 - Study More than a feeling: the role of empathetic care in promoting safety in health care. Citation Text: Leana C, Meuris J, Lamberton C. More Than a Feeling: The Role of Empathetic Care in Promoting Safety in Health Care. ILR Review. 2017;71(2):394-425. doi:10.1177/0019793917720432. C…
  18. psnet.ahrq.gov/issue/impact-diagnostic-management-team-patient-time-diagnosis-and-percent-accurate-and-clinically
    October 19, 2022 - Study Impact of diagnostic management team on patient time to diagnosis and percent of accurate and clinically actionable diagnoses. Citation Text: Brashear J, Mize R, Laposata M, et al. Impact of diagnostic management team on patient time to diagnosis and percent of accurate and clinica…
  19. psnet.ahrq.gov/issue/uptake-quality-related-event-standards-practice-community-pharmacies
    November 09, 2016 - Study Uptake of quality-related event standards of practice by community pharmacies. Citation Text: Boyle TA, Bishop A, Overmars C, et al. Uptake of Quality-Related Event Standards of Practice by Community Pharmacies. J Pharm Pract. 2015;28(5):442-9. doi:10.1177/0897190014522066. Copy …
  20. psnet.ahrq.gov/issue/suffering-silence-medical-error-and-its-impact-health-care-providers
    December 12, 2014 - Review Suffering in silence: medical error and its impact on health care providers. Citation Text: Robertson JJ, Long B. Suffering in Silence: Medical Error and its Impact on Health Care Providers. J Emerg Med. 2018;54(4). doi:10.1016/j.jemermed.2017.12.001. Copy Citation Format: …

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