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  1. Drawing boundaries: the difficulty in defining clinical reasoning. | PSNet

    psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defining-clinical-reasoning
    June 26, 2019 - Commentary Emerging Classic Drawing boundaries: the difficulty in defining clinical reasoning. Citation Text: Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning. Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0…

  2. How doctors think: common diagnostic errors in clinical judgment--lessons from an undiagnosed and rare disease program. | PSNet

    psnet.ahrq.gov/issue/how-doctors-think-common-diagnostic-errors-clinical-judgment-lessons-undiagnosed-and-rare
    September 14, 2022 - Review How doctors think: common diagnostic errors in clinical judgment--lessons from an undiagnosed and rare disease program. Citation Text: Kliegman RM, Bordini BJ, Basel D, et al. How Doctors Think: Common Diagnostic Errors in Clinical Judgment-Lessons from an Undiagnosed and Rare Dis…

  3. Cognitive errors in diagnosis: instantiation, classification, and consequences. | PSNet

    psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classification-and-consequences
    June 21, 2016 - Study Classic Cognitive errors in diagnosis: instantiation, classification, and consequences. Citation Text: Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation, classification, and consequences. Am J Med. 1989;86(4):433-41. Copy Citation …

  4. The objective impact of clinical peer review on hospital quality and safety. | PSNet

    psnet.ahrq.gov/issue/objective-impact-clinical-peer-review-hospital-quality-and-safety
    April 13, 2017 - Study The objective impact of clinical peer review on hospital quality and safety. Citation Text: Edwards MT. The objective impact of clinical peer review on hospital quality and safety. Am J Med Qual. 2011;26(2):110-9. doi:10.1177/1062860610380732. Copy Citation Format: …

  5. Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame. | PSNet

    psnet.ahrq.gov/issue/errors-medicine-punishment-versus-learning-medical-adverse-events-revisited-expanding-frame
    August 24, 2022 - Review Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame. Citation Text: Brattebø G, Flaatten HK. Errors in medicine: punishment versus learning medical adverse events revisited – expanding the frame. Curr Opin Anaesthesiol. 2023;36(2):…

  6. Effect of a hospital command centre on patient safety: an interrupted time series study. | PSNet

    psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study
    July 20, 2022 - Study Effect of a hospital command centre on patient safety: an interrupted time series study. Citation Text: Effect of a hospital command centre on patient safety: an interrupted time series study. Mebrahtu TF, McInerney CD, Benn J, et al. BMJ Health Care Inform. 2023;30(1):e100653…

  7. Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx Spotlight A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion Source and Credits • This presentation is based on the July 2023 AHRQ WebM&M Spotlight Case o See the full article at ht…

  8. Becoming a Patient Safety Organization | PSNet

    psnet.ahrq.gov/perspective/becoming-patient-safety-organization
    July 01, 2011 - Becoming a Patient Safety Organization Rory Jaffe, MD, MBA | July 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. Rockville (MD): Agency for Healthcare …

  9. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough | PSNet

    psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
    September 01, 2003 - SPOTLIGHT CASE Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough Citation Text: Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49868/psn-pdf
    July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With Dementia July 2, 2019 Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia The Case An 86-year-old man with neurode…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867427/psn-pdf
    December 18, 2024 - The Ongoing Journey to Prevent Patient Falls December 18, 2024 Dykes PC, Sousane Z, Mossburg SE. The Ongoing Journey to Prevent Patient Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls Falls are not a new issue, especially among older adults. The Centers for D…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49773/psn-pdf
    July 01, 2016 - Near Miss With Neonate October 1, 2016 Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/near-miss-neonate The Case A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm dates. Early the next morning, intravenous oxy…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49866/psn-pdf
    June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the Operating Room June 1, 2019 Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room The Case A 43-year-old woman was admi…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73387/psn-pdf
    March 17, 2021 - COVID-19 and the Built Environment June 30, 2021 Joseph A, Scanlon MM, Fitall E, et al. COVID-19 and the Built Environment. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/covid-19-and-built-environment Introduction The “built environment” in healthcare refers to the hospital structure and any other fix…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33778/psn-pdf
    March 01, 2015 - Diagnostic Errors January 1, 2014 Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/diagnostic-errors Annual Perspective 2014 Until very recently, diagnostic errors received relatively little attention in the field of patient safety, particularly when compared wi…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49441/psn-pdf
    March 01, 2004 - Fumbled Handoff March 1, 2004 Vidyarthi A. Fumbled Handoff. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/fumbled-handoff The Case A 73-year-old female with history of hypertension, non-insulin dependent diabetes mellitus (NIDDM), and chronic renal insufficiency was admitted for an elective sigmoid resect…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33631/psn-pdf
    April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety April 1, 2006 Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49420/psn-pdf
    October 01, 2003 - To LP or Not LP October 1, 2003 Landrigan CP. To LP or Not LP. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lp-or-not-lp The Case A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with fever and irritability without an obvious source. He was referred to …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49842/psn-pdf
    September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment September 1, 2018 Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment The Case As part of…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33868/psn-pdf
    October 01, 2018 - Safety in the Retail Pharmacy October 1, 2018 Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/safety-retail-pharmacy Perspective There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each year.(1) Many patients interact w…
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