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psnet.ahrq.gov/node/33759/psn-pdf
October 01, 2012 - significant promise to address the patient
safety risks associated with clinical laboratory processes by identifying
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psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - Identifying uses of heparins that circumvent provider orders can lower the risk that a patient with HIT
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psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
May 26, 2021 - Identifying electronic health record contributions to diagnostic error in ambulatory settings through
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psnet.ahrq.gov/node/866826/psn-pdf
September 25, 2024 - Therefore, there may
be a delay in identifying an erroneous cross-connection after a “repair” has been
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psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
August 31, 2022 - non-contrast cranial CT, administering intravenous thrombolysis for suspected acute ischemic stroke, and identifying
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psnet.ahrq.gov/node/867022/psn-pdf
October 30, 2024 - GCS) of 13-15, head CT has a sensitivity ranging from 73% to 99%
and a specificity of 4% to 59% for identifying
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psnet.ahrq.gov/node/33597/psn-pdf
April 10, 2024 - Long-term Care and Patient Safety
April 10, 2024
Bakerjian D. Long-term Care and Patient Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/long-term-care-and-patient-safety
Background
For many years, the patient safety field focused on improving safety in hospital and ambulatory care
settings. More re…
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psnet.ahrq.gov/node/866216/psn-pdf
July 10, 2024 - Health Plan Patient Safety Initiatives
July 10, 2024
Helwig A, Sousane Z, Mossburg S. Health Plan Patient Safety Initiatives. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
When we think of improving patient safety, we often think of strategies that can be implemen…
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psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
March 26, 2015 - Right Place, Right Drug, Wrong Strength
Citation Text:
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/49817/psn-pdf
January 01, 2018 - Slow Down: Right Drug, Wrong Formulation
January 1, 2018
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
The Case
A 65-year-old man presented to his primary care clinic for follow-up after a recent hospitaliz…
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psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
November 21, 2021 - Lapse in Antibiotics Leads to Sepsis
Citation Text:
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
-
psnet.ahrq.gov/node/49432/psn-pdf
February 09, 2004 - Delay in Initiating Antibiotics Results in Fatal Error
February 1, 2004
Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
Case Objectives
Understand the importance of ongoing patient re-evaluati…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.350_slideshow.ppt
June 01, 2015 - PowerPoint Presentation
Spotlight
Anchoring Bias With Critical Implications
1
This presentation is based on the June 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Edward Etchells, MD, MSc, Division of General Internal Medicine, Centre for Q…
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psnet.ahrq.gov/node/49613/psn-pdf
November 01, 2010 - Mother's Milk, but Whose Mother?
November 1, 2010
Dougherty D. Mother's Milk, but Whose Mother? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
The Case
A 2-month-old otherwise healthy infant was admitted to the hospital to rule out sepsis. The infant had been
exclusively breastfed…
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psnet.ahrq.gov/node/49728/psn-pdf
March 01, 2015 - Medication Mix-Up: From Bad to Worse
March 1, 2015
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/medication-mix-bad-worse
The Case
A 69-year-old man with chronic kidney disease and essential hypertension was admitted to the hospital
with chest …
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psnet.ahrq.gov/node/49809/psn-pdf
October 01, 2017 - Hyperbilirubinemia Refractory to Phototherapy
October 1, 2017
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
The Case
A 1-day-old full-term infant was noted to have elevated total serum bilirubin (…
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psnet.ahrq.gov/node/33886/psn-pdf
August 01, 2019 - Medical Scribes and Patient Safety
August 1, 2019
Woodcock D, Bergstrom R. Medical Scribes and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
Perspective
Scribes have supported physicians for thousands of years.(1) However, little is known about how to…
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psnet.ahrq.gov/node/49778/psn-pdf
December 01, 2016 - One Dose, Two Errors
December 1, 2016
Filice GA. One Dose, Two Errors. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/one-dose-two-errors
The Case
A 65-year-old woman was admitted to the intensive care unit (ICU) with severe sepsis and respiratory
failure secondary to community-acquired pneumonia. The pati…
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psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
September 01, 2014 - A Costly Colonoscopy Leads to a Delay in Diagnosis
Citation Text:
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar…
-
psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - July Syndrome
June 1, 2016
Young JQ. July Syndrome. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/july-syndrome
The Case
A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower
lobe lung cancer. The attending surgeon saw the patient along with his fellow,…