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psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - Slippery Slide Into Life
December 1, 2005
Halamek LP. Slippery Slide Into Life. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/slippery-slide-life
The Case
A 25-year-old woman presented to the hospital in labor and at full gestation after receiving uncomplicated
prenatal care. A third-year obstetrics and g…
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psnet.ahrq.gov/node/33672/psn-pdf
September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH
September 1, 2008
In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
Editor's note: Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women's
Hospital and Assi…
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psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
October 30, 2024 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration
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June 14, 2023
Innov…
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - Patient Safety Indicators
Citation Text:
Tokareva I, Romano P. Patient Safety Indicators.. 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/node/73953/psn-pdf
October 27, 2021 - Deprescribing as a Patient Safety Strategy
October 27, 2021
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
Background
Polypharmacy is defined as the act of taking five or more medications on a regular basis…
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psnet.ahrq.gov/web-mm/sick-and-pregnant
August 25, 2021 - Sick and Pregnant
Citation Text:
El-Ibiary S. Sick and Pregnant. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - Alert Fatigue
Citation Text:
Alert Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/conversation-dave-debronkart
June 01, 2014 - co-chair of the Society for Participatory Medicine, Dave deBronkart, also known as e-Patient Dave, is a leading
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psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - co-chair of the Society for Participatory Medicine, Dave deBronkart, also known as e-Patient Dave, is a leading
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - Capnography can detect hypoventilation caused by
decreased respiratory drive leading to a rise in end-tidal
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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/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.
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psnet.ahrq.gov/node/73455/psn-pdf
June 30, 2021 - Paroxysmal Supraventricular Tachycardia Masquerading
as Panic Attacks
June 30, 2021
Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
The Case
At the…
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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.
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - Continuity Errors in Resident Clinic
Citation Text:
Warm EJ. Continuity Errors in Resident Clinic. 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/860050/psn-pdf
January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic
Infant.
January 4, 2024
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
The Case
A 2-month-old full-term male infant was b…
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psnet.ahrq.gov/web-mm/reaction-dye
March 01, 2007 - Reaction to Dye
Citation Text:
Cohan R. Reaction to Dye. 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/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/one-dose-two-errors
September 29, 2017 - One Dose, Two Errors
Citation Text:
Filice GA. One Dose, Two Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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