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  1. Double Trouble | PSNet

    psnet.ahrq.gov/web-mm/double-trouble
    August 01, 2012 - SPOTLIGHT CASE Double Trouble Citation Text: Gurwitz JH. Double Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

  2. Medication Mix-Up: From Bad to Worse | PSNet

    psnet.ahrq.gov/web-mm/medication-mix-bad-worse
    March 01, 2018 - Medication Mix-Up: From Bad to Worse Citation Text: Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote …

  3. Language Barrier | PSNet

    psnet.ahrq.gov/web-mm/language-barrier
    February 28, 2024 - Language Barrier Citation Text: Flores G. Language Barrier. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  4. Hyperglycemia and Switching to Subcutaneous Insulin | PSNet

    psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
    May 19, 2021 - Hyperglycemia and Switching to Subcutaneous Insulin Citation Text: Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Sc…

  5. How Do Providers Recover From Errors? | PSNet

    psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
    May 22, 2024 - SPOTLIGHT CASE How Do Providers Recover From Errors? Citation Text: West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar Bi…

  6. Wrong Catheter in the Right Patient | PSNet

    psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
    May 16, 2022 - Wrong Catheter in the Right Patient Citation Text: Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73434/psn-pdf
    June 30, 2021 - The Consequences of Miscommunication Regarding a Possible Artifact June 30, 2021 Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact Disclosure of Relevant Financial Relationships…

  8. Discharging Our Responsibility | PSNet

    psnet.ahrq.gov/web-mm/discharging-our-responsibility
    January 16, 2019 - Discharging Our Responsibility Citation Text: Fonarow GC. Discharging Our Responsibility. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49639/psn-pdf
    November 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49705/psn-pdf
    January 01, 2020 - A "Reflexive" Diagnosis in Primary Care April 1, 2014 Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care Case Objectives Appreciate that primary care doctors may be caring for an increasing number of patients wi…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49676/psn-pdf
    February 01, 2013 - Death by PCA February 1, 2013 Hicks RW. Death by PCA. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/death-pca The Case A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49552/psn-pdf
    January 01, 2008 - How Do Providers Recover From Errors? January 1, 2008 West CP. How Do Providers Recover From Errors? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors Case Objectives Describe the provider-specific prevalence of medical errors. Appreciate the impact of medical errors on care pr…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33865/psn-pdf
    September 01, 2018 - In Conversation With… Rebecca Lawton, PhD September 1, 2018 In Conversation With… Rebecca Lawton, PhD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd Editor's note: Rebecca Lawton, a Professor in the Psychology of Healthcare at the University of Leeds, is a health psycho…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33707/psn-pdf
    February 01, 2011 - The University of Texas System Clinical Safety and Effectiveness Course February 1, 2011 Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and Effectiveness Course. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33849/psn-pdf
    January 01, 2018 - In Conversation With… Robert Hirschtick, MD January 1, 2018 In Conversation With… Robert Hirschtick, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md Editor's note: Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author of a numbe…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33643/psn-pdf
    December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA December 1, 2006 In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma Editor's Note: J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and Critic…

  17. The Consequences of Miscommunication Regarding a Possible Artifact | PSNet

    psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
    May 11, 2019 - SPOTLIGHT CASE The Consequences of Miscommunication Regarding a Possible Artifact Citation Text: Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…

  18. Low on the Totem Pole | PSNet

    psnet.ahrq.gov/web-mm/low-totem-pole
    October 01, 2003 - SPOTLIGHT CASE Low on the Totem Pole Citation Text: Wachter R. Low on the Totem Pole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33736/psn-pdf
    September 01, 2012 - In Conversation With… Jack Needleman, PhD September 1, 2012 In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management at UCLA School of P…

  20. Diagnostic Error | PSNet

    psnet.ahrq.gov/curated-library/diagnostic-error
    September 14, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Error  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Karen Cosby, AHRQ Date Created: May 8, …
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