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psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
April 24, 2024 - Right Electrocardiogram, Wrong Patient
Citation Text:
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. 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/web-mm/mid-summer-fog
September 29, 2017 - A Mid-Summer Fog
Citation Text:
Braddock CH. A Mid-Summer Fog. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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…
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psnet.ahrq.gov/web-mm/deciphering-code
November 16, 2022 - Deciphering the Code
Citation Text:
Goldstein MK. Deciphering the Code. 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/web-mm/its-all-syringe
February 01, 2013 - It's All in the Syringe
Citation Text:
Weingart SN. It's All in the Syringe. 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/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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psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
July 06, 2022 - Undiagnosed Vaginal Bleeding
Citation Text:
Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient
July 19, 2023 - Acute Care Admission of the Behavioral Health Patient
Citation Text:
Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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…
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psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
June 01, 2005 - Diagnostic Failure: The Growing Deficit
Citation Text:
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/49706/psn-pdf
January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication
Access Issue
April 1, 2014
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
The Case
A 24-year-old wom…
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psnet.ahrq.gov/web-mm/suicidal-man-gun
May 01, 2005 - Suicidal Man With Gun
Citation Text:
Simon RI. Suicidal Man With Gun. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/reconciling-records
September 01, 2017 - Reconciling Records
Citation Text:
Singh H, Sittig DF, Layden M. Reconciling Records. 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/web-mm/missing-point-eye-injury
March 01, 2005 - Missing the Point—Eye Injury
Citation Text:
Sharma R, Brunette DD. Missing the Point—Eye Injury. 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/node/60543/psn-pdf
May 27, 2020 - Wrong Catheter in the Right Patient
May 27, 2020
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
The Case
A 55-year-old man with history of emphysema was admitted to the hospital for pneumonia. The patient had
two?peripheral…
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psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
May 11, 2014 - Vial Mistakes Involving Heparin
Citation Text:
Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - Low on the Totem Pole
December 1, 2005
Wachter R. Low on the Totem Pole. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/low-totem-pole
Case Objectives
Understand the concept of authority gradient
List steps that can be taken to increase communication across an authority gradient
Consider the current cultu…
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psnet.ahrq.gov/node/49432/psn-pdf
February 09, 2004 - Delay in Initiating Antibiotics Results in Fatal Error
February 1, 2004
Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
Case Objectives
Understand the importance of ongoing patient re-evaluati…
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psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd
February 01, 2014 - In Conversation With… Enrico Coiera, MB, BS, PhD
February 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Enrico Coiera, MB, BS, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP
July 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - Continuity Errors in Resident Clinic
Citation Text:
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/periodic-issue/periodic-issue-390
April 26, 2023 - May 10, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, a…