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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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, …
  4. 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
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. 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. Copy Citation Save Save to your library P…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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 …
  10. Psn-Pdf (pdf file)

    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…
  11. 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…
  12. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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. …
  15. Psn-Pdf (pdf file)

    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…
  16. 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. Copy Citation Format: Google Sch…
  17. Psn-Pdf (pdf file)

    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…
  18. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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 …

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