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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - SPOTLIGHT CASE
Out of Sight, Out of Mind: Out-of-Office Test Result Management
Citation Text:
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
March 15, 2023 - E-cigarette Explosion in a Patient Room
Citation Text:
Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
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psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
April 01, 2008 - Anticoagulation: Held Too Long
Citation Text:
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/33765/psn-pdf
April 01, 2014 - In Conversation With… Leah Binder, MA, MGA
April 1, 2014
In Conversation With… Leah Binder, MA, MGA. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga
Editor's note: Leah Binder is President and CEO of The Leapfrog Group, a national nonprofit
representing employers and oth…
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psnet.ahrq.gov/web-mm/slippery-slide-life
January 21, 2017 - Slippery Slide Into Life
Citation Text:
Halamek LP. Slippery Slide Into Life. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
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psnet.ahrq.gov/node/49684/psn-pdf
May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical
Error
May 1, 2013
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet].
2013.
https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
Case Objectives
Appreciate that chemotherapy a…
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psnet.ahrq.gov/node/867805/psn-pdf
February 26, 2025 - If you do things too quickly, you make more
mistakes, including forgetting to do some checks.
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psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
August 01, 2016 - But we know that a lot of mistakes are out of the control of these authorities.
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psnet.ahrq.gov/node/33857/psn-pdf
July 01, 2012 - It kept me from making mistakes. It kept me from spending money
that wasn't necessary.
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psnet.ahrq.gov/node/33728/psn-pdf
May 01, 2012 - of triggers seems to be part of a broader trend in moving from our focus on
identifying errors and mistakes
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psnet.ahrq.gov/node/33789/psn-pdf
August 01, 2015 - relationship,
changes in the way doctors and nurses communicated with each other, and new kinds of medical mistakes
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psnet.ahrq.gov/node/836879/psn-pdf
April 27, 2022 - often-cited sound bite from the 1994 article published by
Lucian Leape that the death toll from medical mistakes
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psnet.ahrq.gov/perspective/safety-dentistry
August 01, 2016 - But we know that a lot of mistakes are out of the control of these authorities.
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes.
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psnet.ahrq.gov/node/838220/psn-pdf
September 27, 2019 - decreasing the time spent with
patients and potentially increasing likelihood of
errors, lapses, and mistakes
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psnet.ahrq.gov/node/851099/psn-pdf
June 28, 2023 - Misconnection Leading to Arterial Thrombosis
June 28, 2023
Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
The Case
A 55-year-old man with chronic obstructive pulmonary disease (COPD) was brought by am…
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - SPOTLIGHT CASE
Right Regimen, Wrong Cancer: Patient Catches Medical Error
Citation Text:
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - Perspective
Patient Safety and Health Information Technology: Learning from Our Mistakes
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
March 27, 2024 - It kept me from making mistakes. It kept me from spending money that wasn't necessary.
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psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - annually.( 2 )
While the IOM report spurred the public and health care profession to focus on medical mistakes