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psnet.ahrq.gov/issue/under-skin-hidden-toll-racism-american-lives-and-health-our-nation
January 04, 2017 - Book/Report
Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation.
Citation Text:
Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation. Villarosa L. New York, NT: Doubleday: 2022. ISBN 9780385544887.
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psnet.ahrq.gov/issue/sent-home-die
April 22, 2020 - Newspaper/Magazine Article
Sent home to die.
Citation Text:
Waldman A, Kaplan J. Sent home to die. ProPublica. 2020.
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psnet.ahrq.gov/issue/perspective-road-map-academic-departments-promote-scholarship-quality-improvement-and-patient
July 02, 2014 - Commentary
Perspective: a road map for academic departments to promote scholarship in quality improvement and patient safety.
Citation Text:
Neeman N, Sehgal NL. Perspective: a road map for academic departments to promote scholarship in quality improvement and patient safety. Acad Med. …
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psnet.ahrq.gov/issue/whose-responsibility-it-address-bullying-health-care
February 22, 2023 - Commentary
Whose responsibility is it to address bullying in health care?
Citation Text:
Whose responsibility is it to address bullying in health care? AMA J Ethics. 2022;23(12):E931-936. doi:10.1001/amajethics.2021.931.
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psnet.ahrq.gov/issue/new-ahrq-sops-workplace-safety-supplemental-item-set-nursing-homes
December 10, 2024 - Meeting/Conference Proceedings
New AHRQ SOPS Workplace Safety Supplemental Item Set for Nursing Homes.
Citation Text:
New AHRQ SOPS Workplace Safety Supplemental Item Set for Nursing Homes. Agency for Healthcare Research and Quality. January 24, 2023.
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psnet.ahrq.gov/issue/global-report-infection-prevention-and-control-executive-summary
March 09, 2022 - Book/Report
Global Report on Infection Prevention and Control: Executive Summary.
Citation Text:
Global Report on Infection Prevention and Control: Executive Summary. Geneva, Switzerland; World Health Organization; May 5, 2022.
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/node/49584/psn-pdf
April 01, 2009 - EMR Entry Error: Not So Benign
April 1, 2009
Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
The Case
A 47-year-old man with advanced AIDS was admitted to an academic medical center with a chief complaint
of shortness of breath. He was …
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psnet.ahrq.gov/node/49455/psn-pdf
July 01, 2004 - The Worst Headache
July 1, 2004
Edlow JA. The Worst Headache. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/worst-headache
The Case
A 48-year-old woman with a history of migraine headaches and hypertension presented to her outpatient
clinic with a 4-day history of headache. While shopping 4 days earlier, …
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psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx
Spotlight
Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full …
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psnet.ahrq.gov/node/49485/psn-pdf
August 29, 2024 - Blind Spot
June 1, 2005
Lee LA. Blind Spot. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/blind-spot
The Case
A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral
position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
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psnet.ahrq.gov/node/49864/psn-pdf
June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You
in Training About Feedback and Burnout
June 1, 2019
Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About
Feedback and Burnout. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - Antibiotics for URI/Sinusitis—A Simple Decision Gone
Bad
April 1, 2008
Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
Case Objectives
Understand the indications for antibiotic treatment in …
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psnet.ahrq.gov/web-mm/worst-headache
July 01, 2016 - The Worst Headache
Citation Text:
Edlow JA. The Worst Headache. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/curated-library/diagnostic-error
November 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Diagnostic Error
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Created By: Karen Cosby, AHRQ
Date Created: May 8, …
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psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
November 01, 2023 - Inadequate Preanesthetic Evaluation, Airway Trouble
Citation Text:
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/860050/psn-pdf
January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic
Infant.
January 4, 2024
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
The Case
A 2-month-old full-term male infant was b…
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psnet.ahrq.gov/issue/adverse-event-reporting-lessons-learned-4-years-florida-office-data
November 16, 2022 - Study
Adverse event reporting: lessons learned from 4 years of Florida office data.
Citation Text:
Coldiron BM, Fisher AH, Adelman E, et al. Adverse event reporting: lessons learned from 4 years of Florida office data. Dermatol Surg. 2005;31(9 Pt 1):1079-92; discussion 1093.
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psnet.ahrq.gov/issue/nhs-sticking-fingers-its-ears-humming-loudly
January 01, 2000 - Study
The NHS: sticking fingers in its ears, humming loudly.
Citation Text:
Pope R. The NHS: Sticking Fingers in Its Ears, Humming Loudly. J Bus Ethics. 2015;145(3):577-598. doi:10.1007/s10551-015-2861-4.
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