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psnet.ahrq.gov/node/36548/psn-pdf
March 03, 2011 - When good doctors go bad: a systems problem.
March 3, 2011
Leape L. When good doctors go bad: a systems problem. Ann Surg. 2006;244(5):649-652.
https://psnet.ahrq.gov/issue/when-good-doctors-go-bad-systems-problem
The author discusses the responsibilities of physicians to help monitor colleagues who may be impaired…
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psnet.ahrq.gov/node/40194/psn-pdf
June 20, 2011 - What happens when things go wrong?
June 20, 2011
Brandom BW, Callahan P, Micalizzi DA. What happens when things go wrong? Paediatr Anaesth.
2011;21(7):730-6. doi:10.1111/j.1460-9592.2010.03513.x.
https://psnet.ahrq.gov/issue/what-happens-when-things-go-wrong
This commentary reveals a personal story of loss and dis…
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psnet.ahrq.gov/node/39381/psn-pdf
March 17, 2010 - Getting it right when things go wrong.
March 17, 2010
Pettker CM, Funai EF. Getting it right when things go wrong. JAMA. 2010;303(10):977-8.
doi:10.1001/jama.2010.256.
https://psnet.ahrq.gov/issue/getting-it-right-when-things-go-wrong
This brief commentary discusses the relationship between blame, accountability, …
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psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
May 01, 2014 - Now without going into too much of the coercive actions that could be promoted at some point, I would
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psnet.ahrq.gov/node/37081/psn-pdf
January 02, 2017 - Miles to go: an introduction to the 5 Million Lives
Campaign.
January 2, 2017
McCannon J, Hackbarth AD, Griffin F. Miles to go: an introduction to the 5 Million Lives Campaign. Jt
Comm J Qual Patient Saf. 2007;33(8):477-84.
https://psnet.ahrq.gov/issue/miles-go-introduction-5-million-lives-campaign
The authors di…
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psnet.ahrq.gov/node/49792/psn-pdf
May 01, 2017 - Diagnostic Delay in the Emergency Department
May 1, 2017
Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
Case Objectives
Appreciate the importance of a broad differential diagnosis for acute abdominal pai…
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psnet.ahrq.gov/issue/medical-apology-making-it-right-when-things-go-wrong
September 01, 2010 - Special or Theme Issue
The Medical Apology: Making It Right When Things Go Wrong.
Citation Text:
The Medical Apology: Making It Right When Things Go Wrong. Schulte MF, ed. Front Health Serv Manage. 2012;28(3):1-46.
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - Anchoring Bias With Critical Implications
June 1, 2015
Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
Case Objectives
Appreciate that diagnostic errors are common in primary and ambulatory care.
Define premature clo…
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psnet.ahrq.gov/node/49478/psn-pdf
April 01, 2005 - Compare and Contrast
April 1, 2005
Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/compare-and-contrast
Case Objectives
Define contrast nephropathy (CN)
List risk factors for CN
Implement pharmacologic strategies for CN prophylaxis
Follow an algorithm for CN risk …
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psnet.ahrq.gov/node/49810/psn-pdf
November 01, 2017 - Palliative Care: Comfort vs. Harm
November 1, 2017
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
Case Objectives
Recognize errors may be difficult to identify in palliative care.
State that medication errors and errors in communica…
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - Implementing a Fall Prevention Program
Frances Healey, RN, PhD | December 1, 2011
View more articles from the same authors.
Citation Text:
Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
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psnet.ahrq.gov/web-mm/compare-and-contrast
July 16, 2019 - SPOTLIGHT CASE
Compare and Contrast
Citation Text:
Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Google Scholar BibTeX EndNote X3 XML End…
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psnet.ahrq.gov/node/49480/psn-pdf
May 01, 2005 - Diagnosing Diagnostic Mistakes
May 1, 2005
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
Learning Objectives
Understand the biases that may contribute to overcalling medical errors
Describe the impact of conside…
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psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Transfer Troubles
June 1, 2012
Hains IM. Transfer Troubles. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfer-troubles
Case Objectives
Recognize that transfer of patients between hospitals is common.
Understand the frequency of errors and adverse events in the transfer of patients between hospitals.
…
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psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - The Wrong Shot: Error Disclosure
June 1, 2004
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
Case Objectives
Describe the rationale for disclosing harmful errors to patients.
Describe the specific information that patie…
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - SPOTLIGHT CASE
The Wrong Shot: Error Disclosure
Citation Text:
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Sch…
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psnet.ahrq.gov/node/49402/psn-pdf
June 01, 2003 - Inappropriate Antibiotic Use
June 1, 2003
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
The Case
A 41-year-old woman presented to the hospital with acute renal failure, which came to be diagnosed as a
first presentation of s…
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psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
September 22, 2010 - Inappropriate Antibiotic Use
Citation Text:
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/node/49475/psn-pdf
March 01, 2005 - Techno Trip
March 1, 2005
Cook RI. Techno Trip. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/techno-trip
The Case
A 70-year-old woman was admitted to a community hospital after developing confusion and right-sided
weakness. A CT scan of her brain showed an acute subdural hematoma. The hospital arranged a…
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psnet.ahrq.gov/node/49643/psn-pdf
December 01, 2011 - More Treatment—Better Care?
December 1, 2011
Redberg R. More Treatment—Better Care? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/more-treatment-better-care
The Case
The patient is a 27-year-old female who presented to a 250-bed community hospital with numbness and
tingling of her hands and feet. She was …