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psnet.ahrq.gov/node/49791/psn-pdf
April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the
Preventable
April 1, 2017
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
The Case
An 84-year-old wo…
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psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
March 04, 2020 - The Hidden Harms of Hand Sanitizer
Citation Text:
Stewart S. The Hidden Harms of Hand Sanitizer. 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/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - restriction of family presence in nursing homes and long-term care communities were observed, especially increases
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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - restriction of family presence in nursing homes and long-term care communities were observed, especially increases
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psnet.ahrq.gov/node/33756/psn-pdf
October 01, 2013 - In Conversation With… Rebecca Smith-Bindman, MD
October 1, 2013
In Conversation With… Rebecca Smith-Bindman, MD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-rebecca-smith-bindman-md
Editor's note: Rebecca Smith-Bindman, MD, is professor in residence at the University of California, San
…
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psnet.ahrq.gov/node/33792/psn-pdf
September 01, 2015 - In Conversation With… Eric J. Topol, MD
September 1, 2015
In Conversation With… Eric J. Topol, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
Editor's note: Eric J. Topol, MD, is Director of Scripps Translational Science Institute, Professor of
Genomics at The Scripps …
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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - SPOTLIGHT CASE
Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.
Citation Text:
Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
Citation Text:
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures
Citation Text:
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - Verbal Orders and Medication Overrides: A Dangerous Combination
Citation Text:
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - Radiology Missed an Intracranial Bleed in a Lethargic Infant.
Citation Text:
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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For…
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging
Citation Text:
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Fo…
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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/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/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/perspective/conversation-withpatrick-s-romano-md-mph
July 10, 2024 - In Conversation with...Patrick S. Romano, MD, MPH
November 1, 2010
Citation Text:
In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.In Conversation with...Patrick S. Romano, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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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/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - Advancing Patient Safety Through State Reporting Systems
Jill Rosenthal, MPH | June 1, 2007
View more articles from the same authors.
Citation Text:
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/node/49846/psn-pdf
November 01, 2018 - Supervision and Entrustment in Clinical Training:
Protecting Patients, Protecting Trainees
November 1, 2018
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees.
PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-pr…
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - SPOTLIGHT CASE
Transfer Troubles
Citation Text:
Hains IM. Transfer Troubles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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