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981. Medication/Drug Errors | PSNet
     psnet.ahrq.gov/curated-library/medicationdrug-errors
     March 12, 2021 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Medication/Drug Errors  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Dr. Yan Xiao, AHRQ TEP Member Date…

982. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49427/psn-pdf
     January 01, 2004 - Inadvertent Castration January 1, 2004 Calland FJ. Inadvertent Castration. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/inadvertent-castration The Case An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently increased in size. The patient described persisten…

983. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49589/psn-pdf
     August 01, 2009 - Hiding in Plain Sight August 1, 2009 Weinberg JM. Hiding in Plain Sight. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/hiding-plain-sight The Case A 65-year-old woman presented to an emergency department (ED) with 48 hours of nontraumatic left lower back pain and general malaise. She was diagnosed with a …

984. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39271/psn-pdf
     February 03, 2010 - The antidote to medical errors. February 3, 2010 Price M. https://psnet.ahrq.gov/issue/antidote-medical-errors This feature article explains how cognitive errors contribute to medical mistakes and describes ways to lessen their occurrence. https://psnet.ahrq.gov/issue/antidote-medical-errors

985. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41263/psn-pdf
     March 29, 2012 - Diagnosis: doubled over in pain. March 29, 2012 Sanders L. https://psnet.ahrq.gov/issue/diagnosis-doubled-over-pain This interactive magazine feature takes readers through the decision-making process in a case involving diagnostic error. https://psnet.ahrq.gov/issue/diagnosis-doubled-over-pain https://psnet.ahrq.…

986. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40505/psn-pdf
     January 27, 2012 - AHRQ 2011 Annual Conference.  January 27, 2012 Agency for Healthcare Research and Quality. Bethesda, MD, September 18-19, 2011. https://psnet.ahrq.gov/issue/ahrq-2011-annual-conference This conference featured leading authorities in health care research and policy. Sessions focused on addressing challenges in impr…

987. The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation | PSNet
     psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
     April 01, 2005 - In addition, the electronic medical record (EMR) features an order set to assist clinicians in ordering

988. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. | PSNet
     psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
     October 31, 2023 - Identify key features of a culture of safety that empowers all team members to express safety concerns

989. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet
     psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
     September 25, 2019 - consultation to a nationally recognized bone pathologist, and the diagnosis of “osteosarcoma with high-grade features

990. Delayed Diagnosis of Endocrinologic Emergencies | PSNet
     psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
     November 13, 2024 - winter months—but it can occur in both sexes and in younger patients as well.( 1 ) The key diagnostic features

991. Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities. | PSNet
     psnet.ahrq.gov/web-mm/challenging-case-multiple-suicide-attempts-complex-patient-psychiatric-comorbidities
     September 27, 2023 - In contrast, bipolar disorder features prolonged and sustained episodes (i.e., at least several

992. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49771/psn-pdf
     July 01, 2016 - It views side effects not as features of reality but rather signs, in Sterman's words, "that our understanding

993. A Sweet Case of Hidden Hydrogen Ions | PSNet
     psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
     November 30, 2023 - Available at  https://www.cdc.gov/diabetes/library/features/diabetes-stat-report.html American

994. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72589/psn-pdf
     December 23, 2020 - Short-term follow-up of palpable breast lesions with benign imaging features: evaluation of 375 lesions

995. E-prescribing: E for error? | PSNet
     psnet.ahrq.gov/web-mm/e-prescribing-e-error
     February 03, 2021 - September 13, 2023 Seven features of safety in maternity units: a framework based on

996. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected | PSNet
     psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
     September 25, 2024 - Features of effective communication during resuscitation are an area of burgeoning research.

997. Implementation of Patient Safety Projects | PSNet
     psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
     November 10, 2025 - Features of successful implementation efforts included change management fundamentals such as planning

998. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37252/psn-pdf
     August 06, 2016 - Safety and Ethics in Healthcare: A Guide to Getting it Right. August 6, 2016 Runciman B, Merry A, Walton M. London, UK: CRC Press; 2017. ISBN: 9781315607443. https://psnet.ahrq.gov/issue/safety-and-ethics-healthcare-guide-getting-it-right This book provides a four-part treatment on improving health care safety, fe…

999. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41874/psn-pdf
     November 21, 2012 - Reducing Diagnostic Errors. November 21, 2012 Boston, MA: National Patient Safety Foundation; 2011. https://psnet.ahrq.gov/issue/reducing-diagnostic-errors This online continuing education module will educate participants on diagnostic errors, including contributing factors and prevention strategies. Dr. Mark Grab…

1000. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39279/psn-pdf
      February 10, 2010 - "I'm sorry": Why is that so hard for doctors to say? February 10, 2010 O'Reilly KB. https://psnet.ahrq.gov/issue/im-sorry-why-so-hard-doctors-say This feature article emphasizes efforts in health care to formalize disclosure following medical errors. https://psnet.ahrq.gov/issue/im-sorry-why-so-hard-doctors-say ht…