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1301. Poorly Advanced Directives | PSNet
      psnet.ahrq.gov/web-mm/poorly-advanced-directives
      August 01, 2018 - Poorly Advanced Directives Citation Text: Anderson WG. Poorly Advanced Directives. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…

1302. Returning Home Safely | PSNet
      psnet.ahrq.gov/web-mm/returning-home-safely
      December 22, 2018 - Returning Home Safely Citation Text: Toles M. Returning Home Safely. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

1303. Abdominal Aortic Aneurysm Screening | PSNet
      psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
      October 01, 2011 - SPOTLIGHT CASE Abdominal Aortic Aneurysm Screening Citation Text: Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX E…

1304. Missed Pneumonia | PSNet
      psnet.ahrq.gov/web-mm/missed-pneumonia
      June 01, 2005 - Missed Pneumonia Citation Text: Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…

1305. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33797/psn-pdf
      January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice January 1, 2016 Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…

1306. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49463/psn-pdf
      October 14, 2004 - Moved Too Soon October 1, 2004 Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/moved-too-soon The Case A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours after arriving, while the patient was still groggy from anesthesia, a nurs…

1307. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49850/psn-pdf
      January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia January 1, 2019 Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia The Case A 72-year-old woman with a history of severe peripheral vascular dis…

1308. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49805/psn-pdf
      September 01, 2017 - The Forgotten Radiographic Read September 1, 2017 Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read The Case A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for management of inferior…

1309. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49389/psn-pdf
      February 01, 2003 - Procedural Mishap: Learning Curve? February 1, 2003 Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve The Case A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had undesired fert…

1310. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49826/psn-pdf
      April 01, 2018 - Air on the Side of Caution April 1, 2018 Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/air-side-caution The Case A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of breath and chest pain. A decision was m…

1311. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49551/psn-pdf
      December 01, 2007 - Too Hot For Comfort December 1, 2007 Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/too-hot-comfort The Case A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV antibiotics via a peripheral line in the left antec…

1312. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49832/psn-pdf
      June 01, 2018 - Febrile Neutropenia and an Almost Fatal Medication Error June 1, 2018 Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error The Case A 33-year-old woman with recently diagnosed acute …

1313. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49791/psn-pdf
      April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable April 1, 2017 Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable The Case An 84-year-old wo…

1314. Urine a Tough Position | PSNet
      psnet.ahrq.gov/web-mm/urine-tough-position
      January 01, 2009 - Urine a Tough Position Citation Text: Gandhi TK. Urine a Tough Position. 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…

1315. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33834/psn-pdf
      May 22, 2017 - Opioid Overdose as a Patient Safety Problem May 22, 2017 Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem Perspective Opioids serve a valuable role in the treatment of acute pain and pain associat…

1316. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33846/psn-pdf
      November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety November 1, 2017 Rozenblum R, Bates DW. The Role of Patient-facing Technologies to Empower Patients and Improve Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-imp…

1317. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49757/psn-pdf
      April 01, 2016 - Situational Awareness and Patient Safety April 1, 2016 Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety The Case A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…

1318. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41314/psn-pdf
      September 27, 2016 - The Medical Apology: Making It Right When Things Go Wrong. September 27, 2016 Schulte MF, ed. Front Health Serv Manage. 2012;28(3):1-46. https://psnet.ahrq.gov/issue/medical-apology-making-it-right-when-things-go-wrong Articles in this special issue highlight lessons learned from disclosure and apology in health c…

1319. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41618/psn-pdf
      August 22, 2012 - Most adverse events at hospitals still go unreported. August 22, 2012 Shaw G. The Hospitalist. August 2012. https://psnet.ahrq.gov/issue/most-adverse-events-hospitals-still-go-unreported This news piece details the pervasiveness of unreported medical errors and describes the hospitalist perspective on initiatives …

1320. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49618/psn-pdf
      February 01, 2011 - One Toxic Drug Is Not Like Another February 1, 2011 Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/one-toxic-drug-not-another Case Objectives Distinguish between the three distinct regulatory processes of board certification, medical licensure, and credential…