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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - A Mid-Summer Fog
Citation Text:
Braddock CH. A Mid-Summer Fog. 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/web-mm/2-week-itch
June 16, 2019 - The 2-Week Itch
Citation Text:
Cohen MR. The 2-Week Itch. 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/node/49689/psn-pdf
August 21, 2013 - Anesthesia: A Weighty Issue
August 21, 2013
Sinha AC. Anesthesia: A Weighty Issue. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/anesthesia-weighty-issue
The Case
A 77-year-old woman was evaluated preoperatively in anticipation of an elective left hip arthroplasty. She
reported having a history of hyperte…
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psnet.ahrq.gov/node/49767/psn-pdf
August 21, 2016 - Falling Between the Cracks in the Software
August 21, 2016
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-between-cracks-software
The Case
A 61-year-old man with a history of osteoarthritis was scheduled for a total knee replacement. Prio…
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psnet.ahrq.gov/node/49743/psn-pdf
September 01, 2015 - Dual Therapy Debacle
September 1, 2015
Kayser SR. Dual Therapy Debacle. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/dual-therapy-debacle
The Case
An elderly man with a history of arthritis, benign prostatic hypertrophy with urinary obstruction,
hyperlipidemia, obesity, and a long history of tobacco use …
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psnet.ahrq.gov/node/33713/psn-pdf
June 01, 2011 - The Safety of Medical Devices
June 1, 2011
Nemeth CP. The Safety of Medical Devices. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/safety-medical-devices
Perspective
Edward Tenner is right. Technology does have reverberations, including unintended consequences, or
"revenge effects."(1) While such dra…
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psnet.ahrq.gov/issue/understanding-and-responding-when-things-go-wrong-key-principles-primary-care-educators
January 23, 2017 - Study
Understanding and responding when things go wrong: key principles for primary care educators.
Citation Text:
McNab D, Bowie P, Ross A, et al. Understanding and responding when things go wrong: key principles for primary care educators. Educ Prim Care. 2016;27(4):258-66. doi:10.1080…
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psnet.ahrq.gov/issue/who-do-hospital-physicians-and-nurses-go-advice-about-medications-social-network-analysis-and
May 22, 2013 - Study
Who do hospital physicians and nurses go to for advice about medications? A social network analysis and examination of prescribing error rates.
Citation Text:
Creswick N, Westbrook JI. Who Do Hospital Physicians and Nurses Go to for Advice About Medications? A Social Network Analys…
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psnet.ahrq.gov/issue/go-between-study-simulation-study-comparing-traffic-lights-and-sbar-tools-means-communication
March 01, 2023 - Study
The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'SBAR' tools as a means of communication between anaesthetic staff.
Citation Text:
MacDougall-Davis SR, Kettley L, Cook TM. The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'S…
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Intubation Mishap
September 1, 2003
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/intubation-mishap
Case Objectives
To understand and apply a structured method of human factors case analysis
To describe the key components of effective teamwork
To understand the imp…
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - SPOTLIGHT CASE
Antiseizure Medication Disorder
Citation Text:
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/49394/psn-pdf
April 01, 2003 - Premature or Overdue?
April 1, 2003
Thomas J, Hannah M. Premature or Overdue? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/premature-or-overdue
The Case
A 32-year-old woman, gravida 3, para 1, presented for prenatal care at 24 weeks. Her past medical history
was unremarkable, and results of her prenatal …
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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…
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psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - Milliliters vs. Milligrams
December 1, 2010
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
The Case
A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His
evaluation showed acu…
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psnet.ahrq.gov/perspective/update-safety-culture
January 22, 2020 - Update on Safety Culture
Allan Frankel, MD, and Michael Leonard, MD | August 22, 2013
View more articles from the same authors.
Citation Text:
Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qual…
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psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
June 16, 2021 - Looking for Meds in All the Wrong Places
Citation Text:
Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/overriding-considerations
March 09, 2009 - Overriding Considerations
Citation Text:
Holtzman NA. Overriding Considerations. 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/wrong-route-nutrients
September 04, 2010 - Wrong Route for Nutrients
Citation Text:
Scott-Cawiezell JR. Wrong Route for Nutrients. 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/web-mm/not-miscarriage
June 01, 2005 - Not a Miscarriage
Citation Text:
Learman LA. Not a Miscarriage. 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/translating-normal-abnormal
October 02, 2019 - SPOTLIGHT CASE
Translating From Normal to Abnormal
Citation Text:
Turner AM. Translating From Normal to Abnormal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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