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  1. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? | PSNet

    psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
    March 01, 2004 - justify using an indicator like death in a low-mortality DRG as a screening test, that, when positive, leads

  2. The Hazards of Distraction: Ticking All the EHR Boxes | PSNet

    psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
    April 09, 2014 - information on the Internet, and the ability to move from topic to topic with just a few keystrokes, leads

  3. In Conversation with Edwin Boudreaux about Suicide Prevention | PSNet

    psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
    March 25, 2025 - Sarah Mossburg : That leads to my next line of questioning around post-screening assessments.

  4. Suicide Prevention | PSNet

    psnet.ahrq.gov/perspective/suicide-prevention
    March 24, 2025 - Sarah Mossburg : That leads to my next line of questioning around post-screening assessments.

  5. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations | PSNet

    psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
    September 27, 2023 - This common cognitive bias leads to premature closure, or the acceptance of a diagnosis before it is

  6. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet

    psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
    September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization Citation Text: Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…

  7. "Recurrent" Appendicitis | PSNet

    psnet.ahrq.gov/web-mm/recurrent-appendicitis
    January 15, 2020 - "Recurrent" Appendicitis Citation Text: Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

  8. Emerging Safety Issues in Artificial Intelligence | PSNet

    psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
    February 20, 2019 - Emerging Safety Issues in Artificial Intelligence Robert Challen, MA, MBBS | July 1, 2019  View more articles from the same authors. Citation Text: Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. Rockville (MD): Agency for Healthcare…

  9. Where's the Feeding Tube? | PSNet

    psnet.ahrq.gov/web-mm/wheres-feeding-tube
    September 01, 2003 - Where's the Feeding Tube? Citation Text: Metheny NA, Meert KL. Where's the Feeding Tube?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

  10. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
    June 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfer Troubles 1 2 Source and Credits This presentation is based on the June 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846770/psn-pdf
    March 29, 2023 - Procedure Complications – Who is Responsible for Follow up? March 29, 2023 Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up? PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow The Case A 74-year-old man with newly diagnose…

  12. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
    May 01, 2017 - PowerPoint Presentation Spotlight Diagnostic Delay in the Emergency Department 1 Source and Credits This presentation is based on the May 2017 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…

  13. A Mistaken Dose of Naloxone  | PSNet

    psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
    March 21, 2009 - A Mistaken Dose of Naloxone  Citation Text: Cutler E, Gunawardena D. A Mistaken Dose of Naloxone . 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 …

  14. The Missing Suction Tip | PSNet

    psnet.ahrq.gov/web-mm/missing-suction-tip
    January 01, 2006 - SPOTLIGHT CASE The Missing Suction Tip Citation Text: Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 …

  15. One Bronchoscopy, Two Errors | PSNet

    psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
    December 09, 2020 - One Bronchoscopy, Two Errors Citation Text: Leiten E, Nielsen R. One Bronchoscopy, Two Errors. 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 XM…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49609/psn-pdf
    October 01, 2010 - Dangerous Dialysis October 1, 2010 Holley JL. Dangerous Dialysis . PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/dangerous-dialysis Case Objectives List common errors that occur in dialysis units. Describe steps that can be taken by dialysis units to prevent these common errors. Describe the role of the …

  17. Shortcuts to Acetaminophen-induced Liver Failure | PSNet

    psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
    July 01, 2017 - Shortcuts to Acetaminophen-induced Liver Failure Citation Text: Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google S…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33882/psn-pdf
    June 01, 2019 - Building a Safety Program Using Principles of Resilience Engineering June 1, 2019 Hegde S, Fairbanks RJ, Bisantz A. Building a Safety Program Using Principles of Resilience Engineering. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering Persp…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49416/psn-pdf
    September 01, 2003 - Check the Bags September 1, 2003 Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/check-bags The Case A 50-year-old man with new atrial fibrillation was placed on a diltiazem drip in the emergency department for rate control. After arriving at the cardiac care unit (CCU…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33790/psn-pdf
    August 01, 2015 - New Insights on Safety and Health IT August 1, 2015 Hettinger ZA, Ratwani RM, Fairbanks RJ. New Insights on Safety and Health IT. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/new-insights-safety-and-health-it Perspective Despite the widespread adoption of electronic health records (EHRs) over the las…
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