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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Despite Clues, Failed to Rescue
August 1, 2017
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
Case Objectives
Define failure to rescue.
Identify the main contributors to failure-to-rescue events.
Appreciate the ongoing areas of scien…
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - SPOTLIGHT CASE
Right Regimen, Wrong Cancer: Patient Catches Medical Error
Citation Text:
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/node/33869/psn-pdf
November 01, 2018 - In Conversation With… David Meltzer, MD, PhD
November 1, 2018
In Conversation With… David Meltzer, MD, PhD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
Editor's note: Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital
Medici…
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psnet.ahrq.gov/node/49491/psn-pdf
September 01, 2005 - Time of Death?
September 1, 2005
Taekman JM, Wright MC. Time of Death? PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/time-death
The Case
An 80-year-old woman with multiple illnesses, including chronic obstructive pulmonary disease (COPD),
was found pulseless and cyanotic in her hospital bed. A code was ca…
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psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
February 26, 2025 - In Conversation With… Eric J. Topol, MD
September 1, 2015
Citation Text:
In Conversation With… Eric J. Topol, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Form…
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation
Save
Save to your library
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August 30, 2023
View more articles from the…
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psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
July 21, 2020 - SPOTLIGHT CASE
Anemia and Delayed Colon Cancer Diagnosis
Citation Text:
Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format: …
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - SPOTLIGHT CASE
One Toxic Drug Is Not Like Another
Citation Text:
Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTe…
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psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
January 13, 2010 - SPOTLIGHT CASE
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
Citation Text:
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - SPOTLIGHT CASE
The Perils of Cross Coverage
Citation Text:
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
May 01, 2007 - Patient Safety in the United Kingdom: Evolution and Progress
Susan Burnett and Charles Vincent, PhD | May 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evol…
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psnet.ahrq.gov/node/845472/psn-pdf
March 15, 2023 - In Conversation with... Dr. Neal Sikka and Dr. Colton Hood
about Remote Patient Monitoring
March 15, 2023
In Conversation with.. Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-…
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - In Conversation with...James P. Bagian, MD
September 1, 2006
Also Read an Essay
Also Read an Essay
Citation Text:
In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.In Conversation with...James P. Bagian, MD. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - Coronavirus Disease 2019 (COVID-19) and Diagnostic
Error
January 11, 2022
Desai AN, Romano PS. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet].
2022.
https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
Originally published July 30, 2020. Updated January …
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psnet.ahrq.gov/issue/clinical-characteristics-and-short-term-outcomes-acute-kidney-injury-missed-diagnosis-older
April 20, 2022 - Study
Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.
Citation Text:
Li Q, Hu P, Kang H, et al. Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis…
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psnet.ahrq.gov/issue/adverse-drug-events-caused-three-high-risk-drug-drug-interactions-patients-admitted-intensive
February 14, 2024 - Study
Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive care units: a multicentre retrospective observational study.
Citation Text:
Klopotowska JE, Leopold J‐H, Bakker T, et al. Adverse drug events caused by three high‐risk drug–drug i…
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psnet.ahrq.gov/issue/evaluation-policies-limiting-opioid-exposure-opioid-prescribing-and-patient-pain-opioid-naive
May 18, 2022 - Study
Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system.
Citation Text:
Rennert L, Howard KA, Walker KB, et al. Evaluation of policies limiting opioid exposure on o…
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psnet.ahrq.gov/issue/emergency-medical-services-responders-perceptions-effect-stress-and-anxiety-patient-safety
January 22, 2016 - Study
Emergency medical services responders' perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study.
Citation Text:
Guise J-M, Hansen M, O'Brien K, et al. Emergency medical services responders' perceptions …
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psnet.ahrq.gov/issue/patient-factors-and-hospital-outcomes-associated-atypical-presentation-hospitalized-older
June 29, 2022 - Study
Patient factors and hospital outcomes associated with atypical presentation in hospitalized older adults with COVID-19 during the first surge of the pandemic.
Citation Text:
Marziliano A, Burns E, Chauhan L, et al. Patient factors and hospital outcomes associated with atypical pres…
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psnet.ahrq.gov/issue/feasibility-patient-reported-diagnostic-errors-following-emergency-department-discharge-pilot
August 19, 2020 - Study
Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study.
Citation Text:
Gleason KT, Peterson SM, Dennison Himmelfarb CR, et al. Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot stud…