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psnet.ahrq.gov/node/49515/psn-pdf
July 01, 2006 - Over Not So Easy
July 1, 2006
Cucina R. Over Not So Easy. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/over-not-so-easy
The Case
A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On
admission, she reported allergies to a number of medications as well as a …
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psnet.ahrq.gov/web-mm/misread-label
August 28, 2024 - Misread Label
Citation Text:
Franklin BD. Misread Label. 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/web-mm/mistaken-identity
December 18, 2014 - Mistaken Identity
Citation Text:
Hall LW. Mistaken Identity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/49457/psn-pdf
September 01, 2004 - Doctor, Don't Treat Thyself
September 1, 2004
Rosvold EO. Doctor, Don't Treat Thyself. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
The Case
A 50-year-old radiologist presented to the emergency department of the community hospital where he
worked and reported increasing shortnes…
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psnet.ahrq.gov/node/49605/psn-pdf
June 01, 2010 - Acute Respiratory Arrest in Pregnancy
June 1, 2010
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
The Case
A 35-year-old woman was 38 weeks pregnant with twins (G3P2). When she developed acute onset of
shortness of breath an…
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psnet.ahrq.gov/node/49554/psn-pdf
January 01, 2008 - Chemotherapy Extravasation
January 1, 2008
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/chemotherapy-extravasation
The Case
A 73-year-old woman with no past medical history was diagnosed with stage IIIA breast cancer. She and
her oncologist decided to begin sys…
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psnet.ahrq.gov/node/49481/psn-pdf
May 01, 2005 - Discharge Against Medical Advice
May 1, 2005
Hwang SW. Discharge Against Medical Advice. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/discharge-against-medical-advice
The Case
A 50-year-old man with a history of alcohol abuse and alcohol-induced dementia was admitted to the
medical service with mild alco…
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psnet.ahrq.gov/node/33731/psn-pdf
June 01, 2012 - An American View of the UK's Patient Safety Enterprise:
Top Down vs. Bottom Up
June 1, 2012
Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
Perspecti…
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psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - The Physical Environment: An Often Unconsidered Patient Safety Tool
Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC | October 1, 2012
View more articles from the same authors.
Citation Text:
Joseph A, Malone EB. The Physical Environment: An Often Unc…
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psnet.ahrq.gov/web-mm/raise-bar
May 29, 2024 - Raise the Bar
Citation Text:
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/finding-fault-default-alert
August 28, 2024 - Finding Fault With the Default Alert
Citation Text:
Baysari M. Finding Fault With the Default Alert. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/do-me-favor
September 12, 2016 - Do Me a Favor
Citation Text:
Williamson A. Do Me a Favor. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/triage-time-bomb
September 01, 2008 - Triage Time Bomb
Citation Text:
Washington DL. Triage Time Bomb. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/49399/psn-pdf
May 01, 2003 - Ectopic or Not?
May 1, 2003
Givens VM, Lipscomb GH. Ectopic or Not? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/ectopic-or-not
The Case
The patient is a 24-year-old woman, gravida 4, para 1, ectopic 1, at 6 weeks from her last menstrual period.
She presents to the emergency department with a 3-day histo…
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psnet.ahrq.gov/node/35786/psn-pdf
May 07, 2007 - When Things Go Wrong: Responding to Adverse Events.
May 7, 2007
Boston, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
https://psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk manage…
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psnet.ahrq.gov/node/49737/psn-pdf
June 01, 2015 - Unseen Perils of Urinary Catheters
June 1, 2015
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
The Case
A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - SPOTLIGHT CASE
One Toxic Drug Is Not Like Another
Citation Text:
Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/dissecting-presentation
May 05, 2021 - SPOTLIGHT CASE
Dissecting the Presentation
Citation Text:
Suat-Ooi SB. Dissecting the Presentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/issue/enhancing-safety-system-wide-situ-simulation-program-using-no-go-considerations
June 13, 2018 - Study
Enhancing safety of a system-wide in situ simulation program using no-go considerations.
Citation Text:
Minors AM, Yusaf TC, Bentley SK, et al. Enhancing safety of a system-wide in situ simulation program using no-go considerations. Simul Healthc. 2023;18(4):226-231. doi:10.1097/si…
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psnet.ahrq.gov/node/44140/psn-pdf
July 15, 2015 - Openness and Honesty When Things Go Wrong: the
Professional Duty of Candour.
July 15, 2015
London, UK: General Medical Council and the Nursing and Midwifery Council; June 29, 2015.
https://psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour
Open and honest discussion with patie…