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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - SPOTLIGHT CASE
Hidden Heparins: HIT Happens
Citation Text:
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride
May 27, 2020
Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
The Case
An infant with trisomy 21 underwent repair of a…
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psnet.ahrq.gov/node/49597/psn-pdf
February 01, 2010 - Adolescent Diabetes: A Routine Visit?
February 1, 2010
Slap GB. Adolescent Diabetes: A Routine Visit? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
Case Objectives
Appreciate the increasing prevalence of obesity and type 2 diabetes mellitus (T2DM) among
adolescents in the…
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psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD
August 1, 2016
Also Read an Essay
Citation Text:
In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Heal…
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psnet.ahrq.gov/node/49566/psn-pdf
July 01, 2008 - What Was in Those Platelets?
July 1, 2008
Yomtovian R. What Was in Those Platelets? . PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/what-was-those-platelets
The Case
A 47-year-old woman was admitted to the hospital for complex spinal surgery. The surgery went well
without complications, and postoperativel…
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - SPOTLIGHT CASE
A Fatal Twist in Pseudohyperkalemia
Citation Text:
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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…
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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer
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July 31, 2023
Innovation
Contact
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psnet.ahrq.gov/web-mm/ebola-are-we-ready
July 01, 2012 - Ebola: Are We Ready?
Citation Text:
Barsuk JH, Barnard C. Ebola: Are We Ready?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/867022/psn-pdf
October 30, 2024 - Delayed Symptomatic Subdural Hematoma Following an
Initially Normal CT Head
October 30, 2024
Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-h…
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psnet.ahrq.gov/issue/role-communication-paediatric-drug-safety
July 08, 2008 - Review
The role of communication in paediatric drug safety.
Citation Text:
Stebbing C, Wong ICK, Kaushal R, et al. The role of communication in paediatric drug safety. Arch Dis Child. 2007;92(5):440-5.
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psnet.ahrq.gov/issue/diagnostic-errors-primary-care-lessons-learned
September 12, 2011 - Study
Diagnostic errors in primary care: lessons learned.
Citation Text:
Ely JW, Kaldjian LC, D'Alessandro DM. Diagnostic errors in primary care: lessons learned. J Am Board Fam Med. 2012;25(1):87-97. doi:10.3122/jabfm.2012.01.110174.
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psnet.ahrq.gov/issue/communication-and-resolution-after-adverse-health-care-incident
August 01, 2014 - Legislation/Regulation
Communication and Resolution After an Adverse Health Care Incident.
Citation Text:
Communication and Resolution After an Adverse Health Care Incident. Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
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psnet.ahrq.gov/issue/health-care-leader-action-guide-reduce-avoidable-readmissions
March 14, 2018 - Book/Report
Health Care Leader Action Guide to Reduce Avoidable Readmissions.
Citation Text:
Health Care Leader Action Guide to Reduce Avoidable Readmissions. Osei-Anto A, Joshi M, Audet AJ, Berman A, Jencks SF. New York, NY: The Commonwealth Fund, The John Hartford Foundation, Healt…
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psnet.ahrq.gov/issue/beyond-organisational-accident-need-error-wisdom-frontline
November 18, 2015 - Commentary
Beyond the organisational accident: the need for "error wisdom" on the frontline.
Citation Text:
Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33.
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psnet.ahrq.gov/issue/national-report-findings-2016-issue-brief-no-2-patient-safety
November 18, 2020 - Book/Report
National Report of Findings 2016: Issue Brief No. 2: Patient Safety.
Citation Text:
National Report of Findings 2016: Issue Brief No. 2: Patient Safety. Clinical Learning Environment Review. Chicago, IL: Accreditation Council for Graduate Medical Education; 2016.
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psnet.ahrq.gov/issue/junior-doctors-shifts-and-sleep-deprivation
October 16, 2012 - Commentary
Junior doctors' shifts and sleep deprivation.
Citation Text:
Murray A, Pounder R, Mather H, et al. Junior doctors' shifts and sleep deprivation. BMJ. 2005;330(7505):1404.
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psnet.ahrq.gov/issue/medication-safety-issue-brief-bar-code-implementation-strategies
June 17, 2014 - Fact Sheet/FAQs
Medication safety issue brief. Bar code implementation strategies.
Citation Text:
Association AH, Pharmacists AS of H-S, Networks H and H. Medication Safety Issue Brief. Bar Code implementation strategies. Hospitals & health networks. 2005;79(7):65-6.
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psnet.ahrq.gov/issue/insulin-pumps-have-most-reported-problems-fda-database
October 03, 2018 - Newspaper/Magazine Article
Insulin pumps have most reported problems in FDA database.
Citation Text:
Insulin pumps have most reported problems in FDA database. Mohr H, Weiss M. Associated Press. November 27, 2018.
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psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake
September 29, 2021 - Newspaper/Magazine Article
RaDonda Vaught says some system practices contributed to fatal mistake.
Citation Text:
RaDonda Vaught says some system practices contributed to fatal mistake. Clark C. MedPage Today. March 14, 2024.
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