-
psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - SPOTLIGHT CASE
How Do Providers Recover From Errors?
Citation Text:
West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar Bi…
-
psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Medication Mix-Up: From Bad to Worse
Citation Text:
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote …
-
psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
Citation Text:
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
-
psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - Failure to Report
March 1, 2007
Spath P. Failure to Report. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/failure-report
Case Objectives
List common causes of medical errors.
Appreciate the magnitude of underreporting of adverse events.
List the common barriers to reporting adverse events and near misses…
-
psnet.ahrq.gov/node/33877/psn-pdf
April 01, 2019 - In Conversation With… Timothy B. McDonald, MD, JD
April 1, 2019
In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
Editor's note: Dr. McDonald is President of the Center for Open and Honest Communication at the
MedStar…
-
psnet.ahrq.gov/node/49516/psn-pdf
August 01, 2006 - Physical Diagnosis: A Lost Art?
August 1, 2006
Thompson GR, Verghese A. Physical Diagnosis: A Lost Art? PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
Case Objectives
Appreciate the decline in proficiency and reliance on physical examination skills among health care
providers.
…
-
psnet.ahrq.gov/node/61078/psn-pdf
October 28, 2020 - Inpatient Stroke Management in an Adolescent with Type
1 Diabetes and Home Insulin Pump
October 28, 2020
Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1
Diabetes and Home Insulin Pump . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/inpatient-stroke-management…
-
psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - The "Customer" Is Always Right
February 1, 2007
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/customer-always-right
Case Objectives
Understand the importance of identifying a patient's agenda.
Appreciate the factors that contribute to unmet patient expectations.
…
-
psnet.ahrq.gov/node/33674/psn-pdf
February 01, 2009 - In Conversation with…Robert M. Wachter, MD
October 1, 2008
In Conversation with…Robert M. Wachter, MD. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
Editor's note: At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and
Chief of the…
-
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 …
-
psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
May 16, 2022 - think is also an interesting aspect of patient safety, that not all parts of the healthcare continuum experience
-
psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - I think we're just starting to get experience with this.
-
psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - 2020
Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience
-
psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - items to
safely count under
most OR conditions
and no alternative
management practice
Variable experience
-
psnet.ahrq.gov/node/867651/psn-pdf
February 26, 2025 - These assessments of the work of medication
administration reflect what we imagine nurses do based on experience
-
psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - Take-Home Points Diagnostic errors are frequent and at least 150,000 patients are estimated to experience
-
psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience
-
psnet.ahrq.gov/node/867035/psn-pdf
October 30, 2024 - Relying on myself: the lived experience of being at risk for
falling in the hospital among older adults
-
psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
November 01, 2008 - think the broader field of patient safety should be learning from your own research and the broader experience
-
psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - Availability
of rtPA and experience with reconstitution and administration of the drug may be limited