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psnet.ahrq.gov/node/36342/psn-pdf
March 02, 2011 - Missed and delayed diagnoses in the ambulatory setting:
a study of closed malpractice claims.
March 2, 2011
Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study
of closed malpractice claims. Ann Intern Med. 2006;145(7):488-496.
https://psnet.ahrq.gov/issue/missed…
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psnet.ahrq.gov/node/42968/psn-pdf
February 26, 2014 - From physician intent to the pharmacy label: prevalence
and description of discrepancies from a cross-sectional
evaluation of electronic prescriptions.
February 26, 2014
Cochran GL, Klepser DG, Morien M, et al. From physician intent to the pharmacy label: prevalence and
description of discrepancies from a cross-se…
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psnet.ahrq.gov/node/45255/psn-pdf
January 23, 2017 - Provider risk factors for medication administration error
alerts: analyses of a large-scale closed-loop medication
administration system using RFID and barcode.
January 23, 2017
Hwang Y, Yoon D, Ahn EK, et al. Provider risk factors for medication administration error alerts: analyses
of a large-scale closed-loop m…
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psnet.ahrq.gov/issue/not-what-doctor-ordered
November 23, 2016 - Newspaper/Magazine Article
Not what the doctor ordered.
Citation Text:
Not what the doctor ordered. Trebilcock B.
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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - Pocket Syringe Swap
Citation Text:
Kulli JC. Pocket Syringe Swap. 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/web-mm/forgotten-turn
August 01, 2018 - ulcers, when they should also be used for high-risk individuals on the "'front end"— before an ulcer occurs
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psnet.ahrq.gov/node/49428/psn-pdf
January 01, 2004 - Otherwise, if the
patient's wishes are unclear and an immediate life threat occurs, it may be prudent
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psnet.ahrq.gov/issue/impact-surgical-count-technology-retained-surgical-items-rates-veterans-health-administration
January 17, 2019 - Study
The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration.
Citation Text:
Gunnar W, Soncrant C, Lynn MM, et al. The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration. J Pat…
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages
Citation Text:
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. 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/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - After a “never event” occurs, clear and explicit disclosure to the patient and/or their family, as
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psnet.ahrq.gov/node/49556/psn-pdf
March 01, 2008 - Hold That Order
March 1, 2008
Grissinger M. Hold That Order. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/hold-order
The Case
A 25-year-old woman with a history of a pituitary tumor was admitted with hypernatremia. Because of her
previous pituitary resection and radiation, the patient had a long history …
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psnet.ahrq.gov/web-mm/pregnant-danger
January 12, 2011 - intimal tear originating within 2 cm of the aortic valve in 75% of cases.( 7 ) The aortic tear commonly occurs
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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - Duty to Disclose Someone Else's Error?
May 1, 2011
Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
Case Objectives
State the rationale for disclosing medical errors.
Describe key principles in effective error disclosure.
…
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - effectiveness of the confirmation process and lessens the
likelihood that effective communication occurs
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psnet.ahrq.gov/node/49725/psn-pdf
January 01, 2015 - checklists (it's a change, a possible slight increase in
time and effort, a bureaucratic exercise, etc.) occurs—until
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psnet.ahrq.gov/node/49412/psn-pdf
September 01, 2003 - Shake Well
September 1, 2003
Flynn EA. Shake Well. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/shake-well
The Case
A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily
serum drug levels consistently fell below the therapeutic range, which led the physi…
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psnet.ahrq.gov/node/49620/psn-pdf
February 01, 2011 - Silent Pain in the Neck
February 1, 2011
Bittner EA. Silent Pain in the Neck. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/silent-pain-neck
The Case
A 60-year-old man with no significant past medical history underwent an elective anterior cervical
discectomy for persistent right arm weakness due to cervi…
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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - Annual Perspective
Patient Safety in the Ambulatory Care Setting
August 5, 2022
View more articles from the same authors.
Citation Text:
Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. Rockville (MD): …
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psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
November 16, 2022 - Annual Perspective
Annual Perspective: Psychological Safety of Healthcare Staff
March 31, 2022
View more articles from the same authors.
Citation Text:
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. P…
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psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
November 13, 2024 - SPOTLIGHT CASE
Abdominal Pain in Early Pregnancy
Citation Text:
Kilpatrick CC. Abdominal Pain in Early Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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