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psnet.ahrq.gov/node/49831/psn-pdf
June 01, 2018 - clinical teams reduced the clinical error rate significantly from
30.9% to 4.4% (p = .039).(16)
Another option
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psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
January 13, 2010 - the context of a small intracranial subarachnoid hemorrhage, unfractionated heparin was a reasonable option
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - it will not alter subsequent testing (i.e., MRI will be obtained, regardless), CT could be the only option
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - A Postpartum Woman with an Erroneous SARS-CoV-2 Test
Citation Text:
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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Forma…
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psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - grounds by immediately rotating the provider to alternative patients or services (though more on this option
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - The Role of Observation
One option that was not utilized in this case was a period of extended observation
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psnet.ahrq.gov/web-mm/double-dose-transfer
November 01, 2012 - Double Dose at Transfer
Citation Text:
Hackman JL. Double Dose at Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/perspective/patient-engagement-safety
January 01, 2018 - Annual Perspective
Patient Engagement in Safety
Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2017
View more articles from the same authors.
Citation Text:
Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/node/865418/psn-pdf
March 27, 2024 - Cybersecurity and How to Maintain Patient Safety
March 27, 2024
Pelletreau B, Riggi J, Gale B, et al. Cybersecurity and How to Maintain Patient Safety. PSNet [internet].
2024.
https://psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
Introduction
The integration of information technology (I…
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psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
November 25, 2020 - The MERC system’s simplicity makes it an attractive option for most obstetric units that have a normal
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - Timely diagnosis of esophageal perforation
Citation Text:
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - psnet.ahrq.gov//#21
https://psnet.ahrq.gov//#20
https://psnet.ahrq.gov//#22
The Role of Observation
One option
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - The Role of Observation One option that was not utilized in this case was a period of extended observation
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - sedating medications on
profile
Set maximum dose limits
with alerts
Have a single
concentration option
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - Emergent surgical decompression of the compartment by cutting the fascia then becomes the only option
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - medications on profile
Set maximum dose limits with alerts
Have a single concentration option
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psnet.ahrq.gov/perspective/patient-safety-home-dialysis
April 28, 2021 - Patient Safety in Home Dialysis
April 28, 2021
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/primer/telehealth-and-patient-safety
July 27, 2022 - Telehealth and Patient Safety.
Citation Text:
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/raise-bar
May 29, 2024 - Raise the Bar
Citation Text:
Stotts J, Lyndon A. Raise the Bar. 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/web-mm/premature-or-overdue
December 23, 2020 - Premature or Overdue?
Citation Text:
Thomas J, Hannah M. Premature or Overdue?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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