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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49417/psn-pdf
    October 01, 2003 - Lost in the Black Hole October 1, 2003 Wachter R. Lost in the Black Hole. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lost-black-hole The Case A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis. She had a remote history of gonorrhea, no environmental exposu…
  2. psnet.ahrq.gov/web-mm/lost-black-hole
    December 01, 2005 - Lost in the Black Hole Citation Text: Wachter R. Lost in the Black Hole. 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 XML Endnote tagged PubMe…
  3. 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…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49719/psn-pdf
    September 01, 2014 - No BP During NIBP September 1, 2014 Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/no-bp-during-nibp The Case An otherwise healthy 49-year-old man with atrial fibrillation was scheduled for ablation in the catheterization laboratory under general endotracheal anes…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49538/psn-pdf
    June 01, 2007 - Abnormal Volunteer Results June 1, 2007 Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results The Case A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent magnetic resonance imaging (MRI) of her abdo…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49641/psn-pdf
    November 01, 2011 - Liver Failure After Chemotherapy: Did We Forget Something? November 1, 2011 Lubel J. Liver Failure After Chemotherapy: Did We Forget Something? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something The Case A 51-year-old Cantonese-speaking female with a his…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33884/psn-pdf
    July 01, 2019 - Emerging Safety Issues in Artificial Intelligence July 1, 2019 Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence Perspective Background Since the beginning of digital health records, there has bee…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43969/psn-pdf
    November 17, 2017 - Transparency when things go wrong: physician attitudes about reporting medical errors to patients, peers, and institutions. November 17, 2017 Bell SK, White AA, Yi JC, et al. Transparency When Things Go Wrong. J Patient Saf. 2015;13(4):243-248. doi:10.1097/pts.0000000000000153. https://psnet.ahrq.gov/issue/transp…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49704/psn-pdf
    March 01, 2014 - Late Anemia Following Rh Disease in a Newborn March 1, 2014 Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn The Case A full-term neonate was delivered uneventfully to an Rh-negative woman who had re…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49724/psn-pdf
    January 01, 2015 - Bowel Injury After Laparoscopic Surgery January 1, 2015 Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery The Case A 30-year-old man presented to the hospital for a scheduled laparoscopic inguinal hernia repair with mes…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49756/psn-pdf
    April 01, 2016 - Lost in Sign Out and Documentation April 1, 2016 Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation The Case A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the emergency physician, …
  12. psnet.ahrq.gov/web-mm/xl-or-smaller
    September 13, 2017 - XL or Smaller? Citation Text: Kozer E. XL or Smaller?. 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 XML Endnote tagged PubMedId RIS …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49860/psn-pdf
    April 01, 2019 - Hip Fractures in Older Patients: the Case for Geriatrics Comanagement April 1, 2019 Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement The Case An 82-year-old man …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49617/psn-pdf
    January 01, 2011 - Failure to Reevaluate December 1, 2010 Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/failure-reevaluate The Case A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community hospital developed methicillin-resistant staphylococc…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33844/psn-pdf
    October 01, 2017 - Health Care Worker Presenteeism: A Challenge for Patient Safety October 1, 2017 Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety Perspective Introduction Health care–as…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49849/psn-pdf
    January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep January 1, 2019 Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep Case Objectives List the patient safety events that are unique to in…
  17. psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
    July 01, 2011 - SPOTLIGHT CASE Spotlight: Mistaken Attribution, Diagnostic Misstep Citation Text: Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citat…
  18. psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
    August 02, 2015 - SPOTLIGHT CASE Despite Clues, Failed to Rescue Citation Text: Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndN…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33836/psn-pdf
    June 01, 2017 - The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed? June 1, 2017 Martin VK, Mirnateghi N, Khoshchehreh M. The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed? . PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed Per…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47005/psn-pdf
    June 13, 2018 - "No-go considerations" for in situ simulation safety. June 13, 2018 Bajaj K, Minors A, Walker K, et al. "No-Go Considerations" for In Situ Simulation Safety. Simul Healthc. 2018;13(3):221-224. doi:10.1097/SIH.0000000000000301. https://psnet.ahrq.gov/issue/no-go-considerations-situ-simulation-safety Frontline simul…

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