-
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,…
-
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
-
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…
-
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…
-
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…
-
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 …
-
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…
-
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 …
-
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 …
-
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…
-
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…
-
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…
-
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…
-
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…
-
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 …
-
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 …
-
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…
-
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…
-
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 …
-
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:
…