-
psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - Many hospitals have experienced a disintegration of their inpatient oncology services, with fewer dedicated
-
psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
January 29, 2021 - relationship with their technologists, and hospitals need to ensure adequate staffing ratios to ensure that experienced
-
psnet.ahrq.gov/web-mm/forgotten-turn
August 01, 2018 - While experts are clearly better at diagnosing pressure ulcers than less well-trained individuals, even experienced
-
psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
March 24, 2025 - We did a survey recently and asked people what was comforting to them when they experienced something
-
psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
July 10, 2024 - The other key element is that we will not produce physicians in practice who actually are experienced
-
psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
June 01, 2017 - This, we hypothesize, is because of the bulk of their postoperative period is then experienced on a Monday
-
psnet.ahrq.gov/web-mm/consequences-medical-overuse
May 05, 2021 - this commentary, we will consider why this elderly patient received overly aggressive cardiac care and experienced
-
psnet.ahrq.gov/node/49854/psn-pdf
February 01, 2019 - Diagnostic Failure: The Growing Deficit
February 1, 2019
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
The Case
A 65-year-old woman with a history of diabetes and hypertension was admitted to a hospital's telem…
-
psnet.ahrq.gov/node/853981/psn-pdf
September 27, 2023 - Walking Out of a Hospital After Attempted Suicide
September 27, 2023
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
The Case
A 42-year-old man with history of posttraumatic stress disorder …
-
psnet.ahrq.gov/node/33719/psn-pdf
October 01, 2011 - The Context Is the Intervention
October 1, 2011
Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/context-intervention
Perspective
Introduction
What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this
context.…
-
psnet.ahrq.gov/node/49596/psn-pdf
December 01, 2009 - Round-Trip Service
December 1, 2009
McGrath MH. Round-Trip Service. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/round-trip-service
The Case
A 70-year-old man with a long history of degenerative joint disease was experiencing increased symptoms
in his left knee. He was referred by his primary care provid…
-
psnet.ahrq.gov/node/865467/psn-pdf
March 27, 2024 - I Just Want to Go Home: Understanding Delirium’s Impact
on Treatment Preferences
March 27, 2024
Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferenc…
-
psnet.ahrq.gov/node/49453/psn-pdf
July 01, 2004 - Bowel Prep
July 1, 2004
Nelson D. Bowel Prep. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/bowel-prep
The Case
The patient is a 73-year-old woman who 20 years ago underwent treatment for breast cancer. At her
daughter's suggestion, the patient requested referral for colonoscopy, as she understood there w…
-
psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Adverse Event During Intrahospital Transport
February 1, 2019
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
The Case
A 4-year-old boy underwent surgery under general anesthesia for correction o…
-
psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - March 12, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
-
psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
-
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/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - These resources were developed with patients and families who had experienced diagnostic error. … the first week of the pandemic in Canada, senior leaders at Kingston General Hospital reached out to experienced
-
psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - These resources were developed with patients and families who had experienced diagnostic error. … the first week of the pandemic in Canada, senior leaders at Kingston General Hospital reached out to experienced