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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - can prompt providers to label patients as "poor historians" ( 5 ), thus providing an excuse for an insufficient … Diagnostic overshadowing also manifests as the process by which an individual receives insufficient or
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psnet.ahrq.gov/sites/default/files/2021-09/Battle%20Buddy%20Pocket%20Card%20-%20final%20(1).pdf
January 01, 2021 - Stressors
•Experiencing working conditions that are hazardous or
have insufficient supplies
•Worrying
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - Anchoring Bias With Critical Implications
June 1, 2015
Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
Case Objectives
Appreciate that diagnostic errors are common in primary and ambulatory care.
Define premature clo…
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psnet.ahrq.gov/node/49514/psn-pdf
July 01, 2006 - Phrased differently, he had insufficient information about the patient's previous medical
treatment
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psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
June 15, 2022 - SPOTLIGHT CASE
Anchoring Bias With Critical Implications
Citation Text:
Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google…
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - SPOTLIGHT CASE
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
Citation Text:
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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psnet.ahrq.gov/issue/safe-practices-drug-allergies-using-cds-and-health-it
March 10, 2021 - Book/Report
Safe Practices for Drug Allergies—Using CDS and Health IT.
Citation Text:
Safe Practices for Drug Allergies—Using CDS and Health IT. Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2019.
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Save
Save to your l…
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psnet.ahrq.gov/node/49696/psn-pdf
December 01, 2013 - New Oral Anticoagulants
December 1, 2013
Fang MC. New Oral Anticoagulants. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/new-oral-anticoagulants
Case Objectives
Review properties of newer target-specific oral anticoagulants (TSOACs) such as dabigatran,
rivaroxaban, and apixaban.
State key perioperative c…
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx
Spotlight
Overdose of Gabapentin and Oxycodone in a Patient
with End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotl…
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psnet.ahrq.gov/issue/patient-safety-culture-nephrology-nurse-practice-settings-initial-findings
August 10, 2022 - Study
Patient safety culture in nephrology nurse practice settings: initial findings.
Citation Text:
Patient safety culture in nephrology nurse practice settings: initial findings. Ulrich B, Kear T. Nephrol Nurs J. 2014;41:459-476.
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psnet.ahrq.gov/issue/demonstration-project-impact-safety-culture-infection-control-practices-hemodialysis
May 01, 2024 - Journal Article
A demonstration project on the impact of safety culture on infection control practices in hemodialysis
Citation Text:
Millson T, Hackbarth D, Bernard HL. A demonstration project on the impact of safety culture on infection control practices in hemodialysis. Am J Infect Co…
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psnet.ahrq.gov/node/49545/psn-pdf
September 01, 2007 - Coming Undone: Failure of Closure Device
September 1, 2007
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
The Case
A 65-year-old man underwent coronary angiography because of atypical exertional chest…
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psnet.ahrq.gov/issue/adverse-outpatient-drug-events-problem-and-opportunity
April 12, 2011 - Commentary
Adverse outpatient drug events—a problem and an opportunity.
Citation Text:
Tierney WM. Adverse outpatient drug events--a problem and an opportunity. N Engl J Med. 2003;348(16):1587-9.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/issue/lax-oversight-leaves-surgery-center-regulators-and-patients-dark
May 17, 2017 - Newspaper/Magazine Article
Lax oversight leaves surgery center regulators and patients in the dark.
Citation Text:
Lax oversight leaves surgery center regulators and patients in the dark. Jewett C, Alesia M. Kaiser Health News. August 9, 2018.
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S…
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psnet.ahrq.gov/issue/trial-automated-decision-support-alerts-contraindicated-medications-using-computerized
May 20, 2019 - Study
A trial of automated decision support alerts for contraindicated medications using computerized physician order entry.
Citation Text:
Galanter W, Didomenico RJ, Polikaitis A. A trial of automated decision support alerts for contraindicated medications using computerized physician…
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psnet.ahrq.gov/issue/physicians-practice-dispensing-medicines-qualitative-study
November 16, 2022 - Study
Physicians' practice of dispensing medicines: a qualitative study.
Citation Text:
Darbyshire D, Gordon M, Baker P, et al. Physicians' Practice of Dispensing Medicines: A Qualitative Study. J Patient Saf. 2016;12(2):82-8. doi:10.1097/PTS.0000000000000122.
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Format:…
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psnet.ahrq.gov/issue/human-factors-surgery-three-mile-island-operating-room
July 12, 2019 - Review
Human factors in surgery: from Three Mile Island to the operating room.
Citation Text:
D'Addessi A, Bongiovanni L, Volpe A, et al. Human factors in surgery: from Three Mile Island to the operating room. Urol Int. 2009;83(3):249-57. doi:10.1159/000241662.
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Form…
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psnet.ahrq.gov/issue/detecting-adverse-drug-reactions-paediatric-wards-intensified-surveillance-versus
May 10, 2023 - Study
Detecting adverse drug reactions on paediatric wards: intensified surveillance versus computerised screening of laboratory values.
Citation Text:
Haffner S, von Laue N, Wirth S, et al. Detecting adverse drug reactions on paediatric wards: intensified surveillance versus computeri…
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psnet.ahrq.gov/issue/frequency-inappropriate-medical-exceptions-quality-measures
July 29, 2020 - Study
Frequency of inappropriate medical exceptions to quality measures.
Citation Text:
Persell SD, Dolan NC, Friesema EM, et al. Frequency of inappropriate medical exceptions to quality measures. Ann Intern Med. 2010;152(4):225-31. doi:10.7326/0003-4819-152-4-201002160-00007.
Copy Ci…
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psnet.ahrq.gov/node/49867/psn-pdf
July 02, 2019 - Diuretics and Electrolyte Abnormalities
July 2, 2019
Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
Case Objectives
Recognize that thiazide diuretics can lead to serious adverse events.
State how commonly used t…