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  1. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists | PSNet

    psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
    February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists Citation Text: Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…

  2. Delay in Initiating Antibiotics Results in Fatal Error | PSNet

    psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
    August 02, 2015 - SPOTLIGHT CASE Delay in Initiating Antibiotics Results in Fatal Error Citation Text: Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation …

  3. Diagnosing a Missed Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
    October 26, 2022 - Diagnosing a Missed Diagnosis Citation Text: Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…

  4. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Elizabeth Gould, NP-C, COR…

  5. Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx Spotlight Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full …

  6. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
    January 01, 2023 - Spotlight Spotlight Prolonged DKA in Pregnancy: A Case of Communication Breakdown Source and Credits • This presentation is based on the August 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Sarah Marshall, MD and Nina M. …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49819/psn-pdf
    February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…

  8. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/867461
    January 31, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Patient and Family Engagement in Long Term Care Curated Library Foundations Long-term Care and Patient Safety Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA | April, 10 2024 A large and growing number of Americans require care in skilled nursin…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867985/psn-pdf
    January 01, 2025 - Suicide Prevention March 25, 2025 Boudreaux E, Gale B, Mossburg SE. Suicide Prevention. PSNet [internet]. 20024. https://psnet.ahrq.gov/perspective/suicide-prevention Introduction Suicide is one of the leading causes of death in the United States, accounting for nearly 50,000 deaths in 2022, a 36% rise since 2000…

  10. Spinal Epidural Abscess | PSNet

    psnet.ahrq.gov/web-mm/spinal-epidural-abscess
    November 13, 2019 - Spinal Epidural Abscess Citation Text: Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

  11. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-469
    December 31, 2024 - January 8, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848109/psn-pdf
    April 26, 2023 - The Danger of 10% Intravenous Calcium Chloride Extravasation. April 26, 2023 The Danger of 10% Intravenous Calcium Chloride Extravasation. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation The Case A 52-year-old man with a history of lymphoplasmacytic lymph…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42498/psn-pdf
    December 30, 2014 - Electronic health record-based triggers to detect potential delays in cancer diagnosis. December 30, 2014 Murphy DR, Laxmisan A, Reis BA, et al. Electronic health record-based triggers to detect potential delays in cancer diagnosis. BMJ Qual Saf. 2014;23(1):8-16. doi:10.1136/bmjqs-2013-001874. https://psnet.ahrq.g…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38981/psn-pdf
    September 30, 2009 - Computerized decision support to reduce potentially inappropriate prescribing to older emergency department patients: a randomized, controlled trial. September 30, 2009 Terrell KM, Perkins AJ, Dexter P, et al. Computerized decision support to reduce potentially inappropriate prescribing to older emergency departme…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41223/psn-pdf
    March 21, 2012 - High-profile investigations into hospital safety problems in England did not prompt patients to switch providers. March 21, 2012 Laverty AA, Smith PC, Pape UJ, et al. High-profile investigations into hospital safety problems in England did not prompt patients to switch providers. Health Aff (Millwood). 2012;31(3):5…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45033/psn-pdf
    July 16, 2019 - A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outpatient settings, and opportunities for improvement. July 16, 2019 Slight SP, Beeler PE, Seger DL, et al. A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outp…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47778/psn-pdf
    March 06, 2019 - Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem. March 6, 2019 Rosenbaum L. Divided We Fall. N Engl J Med. 2019;380(7):684-688. doi:10.1056/NEJMms1813427. https://psnet.ahrq.gov/issue/teamwork-part-1-divided-we-fall-…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45892/psn-pdf
    October 31, 2017 - Relationship between state malpractice environment and quality of health care in the United States. October 31, 2017 Bilimoria KY, Chung JW, Minami CA, et al. Relationship Between State Malpractice Environment and Quality of Health Care in the United States. Jt Comm J Qual Patient Saf. 2017;43(5):241-250. doi:10.1…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48098/psn-pdf
    July 10, 2019 - How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions. July 10, 2019 Salazar A, Karmiy SJ, Forsythe KJ, et al. How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions. Am J Health Syst Pharm. 2019;76(13):970-97…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48139/psn-pdf
    July 17, 2019 - 'Poking the skunk': ethical and medico-legal concerns in research about patients' experiences of medical injury. July 17, 2019 Moore JS, Mello MM, Bismark M. 'Poking the skunk': Ethical and medico-legal concerns in research about patients' experiences of medical injury. Bioethics. 2019;33(8):948-957. doi:10.1111/bi…
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