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psnet.ahrq.gov/node/42449/psn-pdf
July 31, 2013 - The epidemiology of malpractice claims in primary care: a
systematic review.
July 31, 2013
Wallace E, Lowry J, Smith SM, et al. The epidemiology of malpractice claims in primary care: a systematic
review. BMJ Open. 2013;3(7). doi:10.1136/bmjopen-2013-002929.
https://psnet.ahrq.gov/issue/epidemiology-malpractice-cl…
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psnet.ahrq.gov/node/72625/psn-pdf
January 13, 2021 - US clinicians' experiences and perspectives on resource
limitation and patient care during the COVID-19 pandemic.
January 13, 2021
Butler CR, Wong SPY, Wightman AG, et al. US clinicians' experiences and perspectives on resource
limitation and patient care during the COVID-19 pandemic. JAMA Netw Open. 2020;3(11):e20…
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psnet.ahrq.gov/node/60334/psn-pdf
May 13, 2020 - Crisis Standards of Care: Ten Years of Successes and
Challenges–Proceedings of a Workshop.
May 13, 2020
National Academies of Sciences, Engineering, and Medicine. Washington, DC; The National Academies
Press: 2020. ISBN 9780309676250.
https://psnet.ahrq.gov/issue/crisis-standards-care-ten-years-successes-and-…
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psnet.ahrq.gov/node/41322/psn-pdf
November 27, 2012 - Errors of medical interpretation and their potential clinical
consequences: a comparison of professional versus ad
hoc versus no interpreters.
November 27, 2012
Flores G, Abreu M, Barone CP, et al. Errors of medical interpretation and their potential clinical
consequences: a comparison of professional versus ad ho…
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psnet.ahrq.gov/node/60039/psn-pdf
March 11, 2020 - A 25-year-old teacher died after waiting hours at the ER.
She's not the only one who saw delays.
March 11, 2020
Linnane R, Diedrich J. Milwaukee Journal Sentinel. February 25, 2020.
https://psnet.ahrq.gov/issue/25-year-old-teacher-died-after-waiting-hours-er-shes-not-only-one-who-saw-
delays
Delays in emergency r…
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psnet.ahrq.gov/node/45877/psn-pdf
July 19, 2017 - Piece of my mind. Stories doctors tell.
July 19, 2017
Moniz T, Lingard LA, Watling C. Stories Doctors Tell. JAMA. 2017;318(2):124-125.
doi:10.1001/jama.2017.5518.
https://psnet.ahrq.gov/issue/piece-my-mind-stories-doctors-tell
The sharing of stories is a key method to provide context to drive change. The authors e…
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psnet.ahrq.gov/node/840475/psn-pdf
November 30, 2022 - Complexity and challenges of the clinical diagnosis and
management of Long COVID.
November 30, 2022
O’Hare AM, Vig EK, Iwashyna TJ, et al. Complexity and challenges of the clinical diagnosis and
management of Long COVID. JAMA Netw Open. 2022;5(11):e2240332.
doi:10.1001/jamanetworkopen.2022.40332.
https://psnet.ah…
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psnet.ahrq.gov/node/60201/psn-pdf
April 08, 2020 - Misdiagnosis, mistreatment, and harm - when medical
care ignores social forces.
April 8, 2020
Holmes SM, Hansen H, Jenks A, et al. Misdiagnosis, mistreatment, and harm - when medical care ignores
social forces. N Engl J Med. 2020;382(12). doi:10.1056/nejmp1916269.
https://psnet.ahrq.gov/issue/misdiagnosis-mistreat…
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psnet.ahrq.gov/node/846150/psn-pdf
March 15, 2023 - Patient and health care professional perspectives on
stigma in integrated behavioral health: barriers and
recommendations.
March 15, 2023
Phelan SM, Salinas M, Pankey T, et al. Patient and health care professional perspectives on stigma in
integrated behavioral health: barriers and recommendations. Ann Fam Med. 20…
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psnet.ahrq.gov/node/60730/psn-pdf
January 01, 2021 - A machine learning approach to reclassifying
miscellaneous patient safety event reports.
July 29, 2020
Fong A, Behzad S, Pruitt Z, et al. A machine learning approach to reclassifying miscellaneous patient
safety event reports. J Patient Saf. 2021;17(8):e829-e833. doi:10.1097/pts.0000000000000731.
https://psnet.ahr…
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psnet.ahrq.gov/node/47589/psn-pdf
January 09, 2019 - Framework for Effective Board Governance of Health
System Quality.
January 9, 2019
Daley Ullem E, Gandhi TK, Mate K, et al. IHI White Paper. Boston, MA: Institute for Healthcare
Improvement; 2018.
https://psnet.ahrq.gov/issue/framework-effective-board-governance-health-system-quality
The role of hospital boards i…
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psnet.ahrq.gov/node/44604/psn-pdf
August 02, 2016 - Influencing the Quality, Risk and Safety Movement in
Healthcare: In Conversation with International Leaders.
August 2, 2016
Sears K, Stockley D, Broderick B, eds. Aldershot, UK: Ashgate Publishing; 2015. ISBN: 9781472449276.
https://psnet.ahrq.gov/issue/influencing-quality-risk-and-safety-movement-healthcare-conver…
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psnet.ahrq.gov/web-mm/transfusion-slip
June 14, 2011 - Transfusion "Slip"
Citation Text:
Kaplan HS. Transfusion "Slip". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
December 21, 2018 - A Fumbled Handoff to Inpatient Rehab
Citation Text:
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
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psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
February 24, 2021 - SPOTLIGHT CASE
Is the "Surgical Personality" a Threat to Patient Safety?
Citation Text:
Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety?. 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/49696/psn-pdf
December 01, 2013 - New Oral Anticoagulants
December 1, 2013
Fang MC. New Oral Anticoagulants. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/new-oral-anticoagulants
Case Objectives
Review properties of newer target-specific oral anticoagulants (TSOACs) such as dabigatran,
rivaroxaban, and apixaban.
State key perioperative c…
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psnet.ahrq.gov/web-mm/allergy-holter
May 01, 2008 - Allergy to Holter
Citation Text:
Williams M. Allergy to Holter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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…
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psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - Getting the Diagnosis Both Right and Wrong
September 25, 2019
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
The Case
A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
August 01, 2014 - PowerPoint Presentation
Spotlight
Pitfalls in Diagnosing Necrotizing Fasciitis
This presentation is based on the July/August 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Terence Goh, MBBS, Department of Plastic Surgery, Singapore General Hos…
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - A Mistaken Dose of Naloxone?
December 18, 2019
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
The Case
A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up
appointment. He h…