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psnet.ahrq.gov/web-mm/situational-unawareness
August 01, 2009 - Situational (Un)Awareness
Citation Text:
Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/865698/psn-pdf
April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges
April 24, 2024
Leary KB, Lee M, Mossburg S. Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
Introduction
Nurses are essential to patient care, and having a…
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psnet.ahrq.gov/node/853981/psn-pdf
September 27, 2023 - Walking Out of a Hospital After Attempted Suicide
September 27, 2023
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
The Case
A 42-year-old man with history of posttraumatic stress disorder …
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psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
June 16, 2021 - Looking for Meds in All the Wrong Places
Citation Text:
Manias E. Looking for Meds in All the Wrong Places. 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/node/49726/psn-pdf
March 01, 2015 - Two Wrongs Don't Make a Right (Kidney)
March 1, 2015
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
Case Objectives
Review the current definition of wrong-site surgery.
Describe the incidence of wrong-site surgery, and the…
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psnet.ahrq.gov/web-mm/toxic-tachycardia
March 01, 2005 - Toxic Tachycardia
Citation Text:
Wartofsky L. Toxic Tachycardia. 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/node/49424/psn-pdf
November 01, 2003 - Waiting Too Long
November 1, 2003
Rosen MA. Waiting Too Long. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/waiting-too-long
The Case
A 31-year-old gravida 1, para 1 woman presented at 40 weeks in the early stages of labor having received
limited prenatal care at an outside clinic. Physical exam performed…
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psnet.ahrq.gov/node/49447/psn-pdf
June 01, 2004 - Dangerous Dapsone
June 1, 2004
Bookwalter T. Dangerous Dapsone. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/dangerous-dapsone
The Case
A 78-year-old woman with newly diagnosed multiple myeloma on corticosteroids presented to the
emergency department with dyspnea. Upon admission, she was found to be hypo…
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psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - Milliliters vs. Milligrams
December 1, 2010
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
The Case
A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His
evaluation showed acu…
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psnet.ahrq.gov/node/33705/psn-pdf
January 01, 2011 - Risk Management and Patient Safety
December 1, 2010
Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety
Perspective
In 1990, a Harvard-based research team reported the incidence of medical errors …
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - Rescue Improvement Conference Innovation Summary
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July 23, 2024
View more articles from the same authors.
Innovation
Contact
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psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-intervention-innovation
July 23, 2024 - System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary
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September 23, 2024
View more articles from the same…
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - Timely diagnosis of esophageal perforation
Citation Text:
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/rapid-mis-strep
February 01, 2004 - Rapid Mis-St(r)ep
Citation Text:
Kaplan EL. Rapid Mis-St(r)ep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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…
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psnet.ahrq.gov/node/74242/psn-pdf
January 07, 2022 - The Next Step: Use of a Pre-Operative Checklist to
Prevent Missteps
January 7, 2022
Sauder C, Kleber KT. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
The Case
A 52-year-old woman w…
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psnet.ahrq.gov/node/49599/psn-pdf
February 23, 2010 - Defensive Medicine: "Glowing" with Pain
February 1, 2010
Sethi MK. Defensive Medicine: "Glowing" with Pain. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
The Case
A 31-year-old man presented to the emergency department (ED) complaining of abdominal pain and
vomiting. The…
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - Detection of Safety Hazards
September 15, 2024
Detection of Safety Hazards. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/detection-safety-hazards
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient s…
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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - Detection of Safety Hazards
Citation Text:
Detection of Safety Hazards. 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/web-mm/consequences-medical-overuse
May 05, 2021 - SPOTLIGHT CASE
Consequences of Medical Overuse
Citation Text:
Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…