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psnet.ahrq.gov/issue/integrating-human-factors-research-and-surgery-review
August 02, 2015 - Review
Integrating human factors research and surgery: a review.
Citation Text:
Shouhed D, Gewertz BL, Wiegmann D, et al. Integrating human factors research and surgery: a review. Arch Surg. 2012;147(12):1141-1146. doi:10.1001/jamasurg.2013.596.
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psnet.ahrq.gov/issue/lessons-covid-war-investigative-report
March 09, 2022 - Book/Report
Lessons from the Covid War: An Investigative Report.
Citation Text:
Lessons from the Covid War: An Investigative Report. Covid Crisis Group. New York: Public Affairs; 2023. ISBN: 9781541703803.
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psnet.ahrq.gov/issue/application-human-error-theory-case-analysis-wrong-procedures
November 14, 2018 - Study
Application of human error theory in case analysis of wrong procedures.
Citation Text:
Duthie EA. Application of Human Error Theory in Case Analysis of Wrong Procedures. J Patient Saf. 2010;6(2):108-114. doi:10.1097/pts.0b013e3181de47f9.
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psnet.ahrq.gov/issue/checklist-improve-patient-safety-interventional-radiology
September 20, 2011 - Study
A checklist to improve patient safety in interventional radiology.
Citation Text:
Koetser ICJ, de Vries EN, van Delden OM, et al. A checklist to improve patient safety in interventional radiology. Cardiovasc Intervent Radiol. 2013;36(2):312-9. doi:10.1007/s00270-012-0395-z.
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psnet.ahrq.gov/issue/lost-art-history-and-physical
May 08, 2013 - Commentary
The lost art of the history and physical.
Citation Text:
Natt B, Szerlip HM. The lost art of the history and physical. Am J Med Sci. 2014;348(5):423-5. doi:10.1097/MAJ.0000000000000326.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote…
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psnet.ahrq.gov/issue/principles-pediatric-patient-safety-reducing-harm-due-medical-care
May 22, 2019 - Organizational Policy/Guidelines
Principles of pediatric patient safety: reducing harm due to medical care.
Citation Text:
Mueller BU, Neuspiel DR, Fisher ERS, et al. Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care. Pediatrics. 2019;143(2):e20183649. doi:10.1542…
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psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classification-and-consequences
June 21, 2016 - Study
Classic
Cognitive errors in diagnosis: instantiation, classification, and consequences.
Citation Text:
Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation, classification, and consequences. Am J Med. 1989;86(4):433-41.
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psnet.ahrq.gov/issue/objective-impact-clinical-peer-review-hospital-quality-and-safety
April 13, 2017 - Study
The objective impact of clinical peer review on hospital quality and safety.
Citation Text:
Edwards MT. The objective impact of clinical peer review on hospital quality and safety. Am J Med Qual. 2011;26(2):110-9. doi:10.1177/1062860610380732.
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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,…
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psnet.ahrq.gov/node/33644/psn-pdf
December 01, 2006 - Establishing a Safety Culture: Thinking Small
December 1, 2006
Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
Perspective
Safety cultures are the holy grail in any risky industry. Like all holy grails, th…
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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 …
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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 …
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psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - Benefits vs. Risks of Intraosseous Vascular Access
August 21, 2014
Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
The Case
A 72-year-old woman with a history of asthma, congestive heart…
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psnet.ahrq.gov/node/49404/psn-pdf
June 01, 2003 - Not a Miscarriage
June 1, 2003
Learman LA. Not a Miscarriage. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/not-miscarriage
The Case
A 32-year-old woman, gravida 3, para 1, with a history of Type 2 diabetes mellitus on metformin, presented
at 7 and 2/7 weeks by last menstrual period (LMP). The patient rep…
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psnet.ahrq.gov/node/49548/psn-pdf
October 01, 2007 - Toxic Tachycardia
October 1, 2007
Wartofsky L. Toxic Tachycardia. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/toxic-tachycardia
The Case
A 66-year-old woman with a past medical history of hypertension and breast cancer was admitted with
abdominal pain. She complained of 3 weeks of progressive severe rig…
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
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psnet.ahrq.gov/node/867980/psn-pdf
March 25, 2025 - Not All Headaches are Due to Migraine: Red Flags, Don’t
Miss Diagnoses, and Diagnostic Pitfalls
March 25, 2025
Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic
Pitfalls. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-fla…
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psnet.ahrq.gov/web-mm/outpatient-zebra
January 23, 2020 - An Outpatient 'Zebra'
Citation Text:
Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
September 01, 2007 - In Conversation with...Atul Gawande, MD, MA, MPH
September 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Atul Gawande, MD, MA, MPH. PSNet [internet]. 2007.In Conversation with...Atul Gawande, MD, MA, MPH. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case
Citation Text:
Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US …