-
psnet.ahrq.gov/web-mm/code-blue-where
March 30, 2020 - May not relieve EMTALA obligation Code Blue Team Standard hospital "crash team" Experienced
-
psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - In this case, the pharmacist and the nurse both may have experienced confirmation bias as they believed
-
psnet.ahrq.gov/curated-library/artificial-intelligence-system-level-considerations
March 27, 2024 - regulators and legal experts will need to consider how to manage compensation for patients who have experienced
-
psnet.ahrq.gov/curated-library/diagnostic-error
August 10, 2025 - extrapolating these results, since malpractice claims only account for a small proportion of all adverse events experienced
-
psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
January 01, 2024 - While labetalol initially helped control the patient’s blood pressure, she experienced persistent hypertension
-
psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - to recommend that patients who had changes in their warfarin dose, had new medications started, or experienced
-
psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - Patients who have not experienced errors report that, if a harmful error occurred in their treatment,
-
psnet.ahrq.gov/web-mm/worst-headache
July 01, 2016 - While shopping 4 days earlier, she experienced sudden onset of a severe diffuse headache—"maybe the worst
-
psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
January 01, 2024 - problem-solving.1
12
12
Communication Issues
13
Communication Issues (1)
Most notably, this patient’s team experienced
-
psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - perceived to be time consuming, repetitive, and seemingly uncomplicated, such as infant feedings.( 3 ) Experienced
-
psnet.ahrq.gov/web-mm/one-dose-two-errors
September 29, 2017 - One Dose, Two Errors
Citation Text:
Filice GA. One Dose, Two Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
-
psnet.ahrq.gov/web-mm/code-status-vs-care-status
September 30, 2020 - Decades of data demonstrate healthcare’s systemic racism and the many barriers to care experienced by
-
psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
December 01, 2012 - Patients received therapy for 87% of study days, and experienced an average of 2 fewer days of delirium
-
psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - Check the Anesthesia Machine
Citation Text:
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML End…
-
psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
November 04, 2015 - Patient Safety in the Physician Office Setting
Nancy C. Elder, MD, MSPH | May 1, 2006
View more articles from the same authors.
Citation Text:
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
-
psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable
Citation Text:
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Ci…
-
psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - An Easily Forgotten Tube
Citation Text:
Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
-
psnet.ahrq.gov/node/49694/psn-pdf
October 01, 2013 - Are You Mrs. A? An Issue of Identification Over
Telephone
October 1, 2013
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
The Case
Mr. A was a 78-year-old man admitted with non-ST elevation…
-
psnet.ahrq.gov/node/33651/psn-pdf
June 01, 2007 - In Conversation with...Diane Rydrych, MA
June 1, 2007
In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
Editor's Note: Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota
Department of Health,…
-
psnet.ahrq.gov/node/33624/psn-pdf
December 01, 2005 - In Conversation with…Troyen A. Brennan, MD, JD, MPH
December 1, 2005
In Conversation with…Troyen A. Brennan, MD, JD, MPH. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
Dr. Robert Wachter, Editor, AHRQ WebM&M: What got you interested in the law and its interface…