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psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
March 01, 2007 - The Role of the Patient in Improving Patient Safety
Rosemary Gibson, MSc | March 1, 2007
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Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. Rockville…
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psnet.ahrq.gov/node/866343/psn-pdf
December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure
with Hypertensive Emergency
December 31, 2024
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive
Emergency. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hyperte…
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - SPOTLIGHT CASE
The Safety and Quality of Long Term Care
Citation Text:
Vogelsmeier AA. The Safety and Quality of Long Term Care. 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/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors
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March 3, 2021
Innovation…
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psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
November 13, 2024 - SPOTLIGHT CASE
Abdominal Pain in Early Pregnancy
Citation Text:
Kilpatrick CC. Abdominal Pain in Early Pregnancy. 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/node/49771/psn-pdf
July 01, 2016 - Unintended Consequences of CPOE
October 1, 2016
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
Case Objectives
Explain how technology, including computerized provider order entry, can transform, rather than
eliminate, hazards.
Recogni…
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - SPOTLIGHT CASE
A Weighty Mistake
Citation Text:
Bokser SJ. A Weighty Mistake. 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/dangerous-shift
July 24, 2013 - SPOTLIGHT CASE
Dangerous Shift
Citation Text:
Patterson ES. Dangerous Shift. 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/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - Advancing Patient Safety Through State Reporting Systems
Jill Rosenthal, MPH | June 1, 2007
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Citation Text:
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - SPOTLIGHT CASE
Unexplained Apnea Under Anesthesia
Citation Text:
Barach P. Unexplained Apnea Under Anesthesia. 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/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures
Citation Text:
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
July 01, 2012 - EMR Entry Error: Not So Benign
Citation Text:
Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/volume-too-low-and-out
July 01, 2017 - SPOTLIGHT CASE
Volume Too Low: In and Out
Citation Text:
Miller MR. Volume Too Low: In and Out . 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/node/840174/psn-pdf
August 28, 2024 - Missed CANDOR Implementation Opportunities.
November 16, 2022
Schweitzer L. Missed CANDOR Implementation Opportunities. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
The Case
A 58-year-old man with a history of type 2 diabetes mellitus, hypertension, morbid obesit…
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psnet.ahrq.gov/node/33580/psn-pdf
April 01, 2022 - Nursing and Patient Safety
April 21, 2021
Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/nursing-and-patient-safety
Updated in March 2021. Originally published in December 2011 by researchers at the University of
California, San Francisco. …
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psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout
Citation Text:
Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - Blind Spot
Citation Text:
Lee LA. Blind Spot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - Patient factors and the history of present illness contribute to wound outcomes.
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psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
January 01, 2018 - Copy and paste of electronic health records: a modern medical illness. Am J Med. 2010;123:e9.
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psnet.ahrq.gov/perspective/conversation-rebecca-smith-bindman-md
October 01, 2013 - October 1, 2013
Perspective
The use of medical imaging to depict and to help diagnose illness