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psnet.ahrq.gov/node/33607/psn-pdf
September 27, 2022 - system-level concerns that can
have significant safety, quality, economic and organizational performance implications
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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - The Forgotten Radiographic Read
Citation Text:
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49433/psn-pdf
June 23, 2021 - Environmental Safety in the OR
February 1, 2004
Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/environmental-safety-or
The Case
The infection control department of a hospital noticed a marked increase in the rates of post-operative
sternal wound inf…
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psnet.ahrq.gov/node/33724/psn-pdf
February 01, 2012 - In Conversation With… Lawrence Smith, MD
February 1, 2012
In Conversation With… Lawrence Smith, MD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
Editor's note: Lawrence G. Smith, MD, is the founding Dean of Hofstra North Shore-LIJ School of
Medicine and Executive Vice P…
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Patient Identification Errors: A Systems Challenge
Citation Text:
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/environmental-safety-or
May 19, 2015 - Environmental Safety in the OR
Citation Text:
Linkin DR, Lautenbach E. Environmental Safety in the OR . 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/fire-hole-or-fire
August 03, 2017 - Fire in the Hole!—An OR Fire
Citation Text:
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. 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/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - CYP450 Drugs: Expect the Unexpected
Citation Text:
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. 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/may-i-have-another-medication-error
March 01, 2009 - Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274:29-34.
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - A systematic review of the literature on the evaluation of handoff tools: implications for research and
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psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
December 07, 2009 - Follow-up of markedly elevated serum potassium results in the ambulatory setting: implications for patient
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - The mother, a medical student, realized the potential implications of such an error and asked the resident
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - There are many implications for further study of patient safety during intrahospital transport of acutely
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psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
March 15, 2023 - E-cigarettes: use, effects on smoking, risks, and policy implications.
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - Cases
Critical Opportunity Lost
March 1, 2015
The safety implications
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psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - Deficits in communication
and information transfer between hospital-based and primary care physicians: implications
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - 2017
WebM&M Cases
Anchoring Bias With Critical Implications
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psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - Nevertheless, errors do occur and their implications can be severe if they result in
inappropriate triage
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - Incidence, risk factors, and clinical implications of postoperative hematoma requiring reoperation
following
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Incidence of adverse drug events and potential adverse drug events:
implications for prevention.