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psnet.ahrq.gov/issue/educational-opportunities-postevent-debriefing
May 28, 2015 - Commentary
Educational opportunities with postevent debriefing.
Citation Text:
Mullan PC, Kessler DO, Cheng A. Educational opportunities with postevent debriefing. JAMA. 2014;312(22):2333-4. doi:10.1001/jama.2014.15741.
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psnet.ahrq.gov/issue/report-mid-staffordshire-nhs-foundation-trust-public-inquiry
November 06, 2015 - Book/Report
Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry.
Citation Text:
Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry. Francis R. London, UK: The Stationary Office; 2013. ISBN: 9780102981469.
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psnet.ahrq.gov/issue/national-voluntary-consensus-standards-patient-safety-measures-consensus-report
January 11, 2013 - Book/Report
National Voluntary Consensus Standards for Patient Safety Measures: A Consensus Report.
Citation Text:
National Voluntary Consensus Standards for Patient Safety Measures: A Consensus Report. Washington, DC: National Quality Forum; June 2012.
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psnet.ahrq.gov/issue/importance-cognitive-errors-diagnosis-and-strategies-minimize-them
September 18, 2024 - Study
Classic
The importance of cognitive errors in diagnosis and strategies to minimize them.
Citation Text:
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.
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psnet.ahrq.gov/issue/cultures-caring-healthcare-scandals-inquiries-and-remaking-accountabilities
September 07, 2022 - Commentary
Cultures of caring: healthcare 'scandals', inquiries, and the remaking of accountabilities.
Citation Text:
Goodwin D. Cultures of caring: Healthcare 'scandals', inquiries, and the remaking of accountabilities. Soc Stud Sci. 2018;48(1):101-124. doi:10.1177/0306312717751051.
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psnet.ahrq.gov/issue/when-medical-error-becomes-personal-activism-becomes-painful
August 21, 2019 - Newspaper/Magazine Article
When medical error becomes personal, activism becomes painful.
Citation Text:
When medical error becomes personal, activism becomes painful. Millenson M. Forbes. September 16, 2022.
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psnet.ahrq.gov/issue/improving-diagnosis-improving-education-policy-brief-education-healthcare-professions
August 28, 2019 - Commentary
Improving diagnosis by improving education: a policy brief on education in healthcare professions.
Citation Text:
Graber ML, Rencic J, Rusz D, et al. Improving diagnosis by improving education: a policy brief on education in healthcare professions. Diagnosis (Berl). 2018;5(3):…
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psnet.ahrq.gov/issue/confronting-racism-pediatric-care
February 22, 2023 - Commentary
Confronting racism in pediatric care.
Citation Text:
Danielson B. Confronting racism in pediatric care. Health Affairs. 2022;41(11):1681-1685. doi:10.1377/hlthaff.2022.01157.
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psnet.ahrq.gov/issue/acog-committee-opinion-590-preparing-clinical-emergencies-obstetrics-and-gynecology
May 22, 2019 - Commentary
ACOG Committee Opinion #590: preparing for clinical emergencies in obstetrics and gynecology.
Citation Text:
Improvement AC of O and GC on PS and Q. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014;123(3):722-5. d…
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.
Citation Text:
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
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psnet.ahrq.gov/web-mm/check-wristband
August 03, 2009 - Check the Wristband
Citation Text:
Rosenthal M. Check the Wristband. 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/doctor-dont-treat-thyself
August 21, 2024 - Doctor, Don't Treat Thyself
Citation Text:
Rosvold EO. Doctor, Don't Treat Thyself. 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/unfamiliar-catheter
November 01, 2006 - The Unfamiliar Catheter
Citation Text:
Swayze SC, James A. The Unfamiliar Catheter. 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/breakage-picc-line
June 21, 2023 - SPOTLIGHT CASE
Breakage of a PICC Line
Citation Text:
Dimov V. Breakage of a PICC Line. 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/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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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.
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psnet.ahrq.gov/web-mm/undetected-foreign-object
April 24, 2018 - Undetected Foreign Object
Citation Text:
Cima RR. Undetected Foreign Object. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/july-syndrome
July 01, 2011 - July Syndrome
Citation Text:
Young JQ. July Syndrome. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/49865/psn-pdf
June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy
June 1, 2019
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
The Case
A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
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psnet.ahrq.gov/node/33839/psn-pdf
August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of
Northwester…