-
psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - Do Not Disturb!
October 1, 2007
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/do-not-disturb
Case Objectives
Define professionalism.
Discuss behaviors associated with lack of professionalism.
Outline steps one should take if a significant breach of professionalism is …
-
psnet.ahrq.gov/node/49675/psn-pdf
February 01, 2013 - Delay in Treatment: Failure to Contact Patient Leads to
Significant Complications
February 1, 2013
Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet
[internet]. 2013.
https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complicat…
-
psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - The Wet Read
March 1, 2006
Arenson RL. The Wet Read. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/wet-read
Case Objectives
Appreciate the limitations of radiology resident emergency coverage.
Understand the rate of discrepancy between radiology resident preliminary reads and attending
radiologists' fina…
-
psnet.ahrq.gov/node/49454/psn-pdf
July 01, 2004 - Novel Drug Misuse
July 1, 2004
Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/novel-drug-misuse
Case Objectives
Define the inclusion and exclusion criteria for patients in PROWESS.
Understand why the FDA included APACHE score as an indication criterion for drotrec…
-
psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
Linkedin
Copy URL
June 12, 2020
…
-
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…
-
psnet.ahrq.gov/node/862983/psn-pdf
February 28, 2024 - Airway Obstruction during Anterior Cervical Spine
Surgery
February 28, 2024
Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
The Case
A 47-year-old obese man (body weight 13…
-
psnet.ahrq.gov/node/49786/psn-pdf
March 01, 2017 - Consequences of Medical Overuse
March 1, 2017
Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/consequences-medical-overuse
Case Objectives
Define overuse and overdiagnosis.
State how much of all care is estimated to be overuse.
Describe why the likelihood…
-
psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
Citation Text:
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
-
psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - SPOTLIGHT CASE
Failure to Report
Citation Text:
Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
-
psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures
Citation Text:
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citation
Format:
…
-
psnet.ahrq.gov/issue/6-pack-programme-decrease-fall-injuries-acute-hospitals-cluster-randomised-controlled-trial
December 21, 2014 - Study
Classic
6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial.
Citation Text:
Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled t…
-
psnet.ahrq.gov/issue/errare-humanum-est-frequency-laterality-errors-radiology-reports
September 13, 2023 - Study
Errare humanum est: frequency of laterality errors in radiology reports.
Citation Text:
Sangwaiya MJ, Saini S, Blake MA, et al. Errare humanum est: frequency of laterality errors in radiology reports. AJR Am J Roentgenol. 2009;192(5):W239-44. doi:10.2214/AJR.08.1778.
Copy Citatio…
-
psnet.ahrq.gov/issue/community-acquired-and-hospital-acquired-medication-harm-among-older-inpatients-and-impact
August 28, 2024 - Study
Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medication management intervention.
Citation Text:
Pellegrin K, Lozano A, Miyamura J, et al. Community-acquired and hospital-acquired medication harm among older inpatients an…
-
psnet.ahrq.gov/issue/impact-use-employee-functional-flexibility-patient-safety
January 12, 2022 - Study
The impact of the use of employee functional flexibility on patient safety.
Citation Text:
Salvador RO, Gnanlet A, McDermott C. The impact of the use of employee functional flexibility on patient safety. Personnel Rev. 2020;50(3):971-984. doi:10.1108/pr-10-2019-0562.
Copy Citatio…
-
psnet.ahrq.gov/issue/diagnostic-errors-pediatric-critical-care-systematic-review
April 06, 2016 - Review
Diagnostic errors in pediatric critical care: a systematic review.
Citation Text:
Cifra CL, Custer J, Singh H, et al. Diagnostic errors in pediatric critical care: a systematic review. Pediatr Crit Care Med. 2021;22(8):701-712. doi:10.1097/pcc.0000000000002735.
Copy Citation
…
-
psnet.ahrq.gov/issue/i-am-administering-medication-please-do-not-interrupt-me-red-tabards-preventing-interruptions
May 12, 2021 - Study
"I am administering medication—please do not interrupt me": red tabards preventing interruptions as perceived by surgical patients.
Citation Text:
Palese A, Ferro M, Pascolo M, et al. "I Am Administering Medication-Please Do Not Interrupt Me": Red Tabards Preventing Interruptions a…
-
psnet.ahrq.gov/issue/errors-administration-parenteral-drugs-intensive-care-units-multinational-prospective-study
September 30, 2010 - Study
Errors in administration of parenteral drugs in intensive care units: multinational prospective study.
Citation Text:
Valentin A, Capuzzo M, Guidet B, et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ. 2009;338:b814.…
-
psnet.ahrq.gov/issue/covid-19-has-united-patients-and-providers-against-institutional-betrayal-health-care-battle
June 29, 2009 - Commentary
COVID-19 has united patients and providers against institutional betrayal in health care: a battle to be heard, believed, and protected.
Citation Text:
Klest B, Smith CP, May C, et al. COVID-19 has united patients and providers against institutional betrayal in health care: a …
-
psnet.ahrq.gov/issue/impact-regionalized-care-concordance-plan-and-preventable-adverse-events-general-medicine
November 16, 2022 - Study
Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services.
Citation Text:
Mueller SK, Schnipper JL, Giannelli K, et al. Impact of regionalized care on concordance of plan and preventable adverse events on general medicine service…