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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…
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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.
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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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P…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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, …
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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.
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…
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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 …
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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…
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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…
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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…
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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.
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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.
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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…
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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…