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psnet.ahrq.gov/node/44957/psn-pdf
March 09, 2016 - Government and industry fail to protect the public when
they suggest "carefully following instructions" is enough
to prevent vaccine errors.
March 9, 2016
ISMP Medication Safety Alert! Acute care edition. February 25, 2016;21(4):1-5.
https://psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-the…
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psnet.ahrq.gov/node/837201/psn-pdf
May 25, 2022 - Near miss research in the healthcare system: a scoping
review.
May 25, 2022
Feng T-ting, Zhang X, Tan L-ling, et al. Near miss research in the healthcare system: a scoping review. J
Nurs Adm. 2022;52(3):160-166. doi:10.1097/nna.0000000000001124.
https://psnet.ahrq.gov/issue/near-miss-research-healthcare-system-sco…
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psnet.ahrq.gov/node/60152/psn-pdf
March 25, 2020 - Errors during resuscitation: the impact of perceived
authority on delivery of care.
March 25, 2020
Delaloye NJ, Tobler K, O?Neill T, et al. Errors during resuscitation: the impact of perceived authority on
delivery of care. J Patient Saf. 2020;16(1). doi:10.1097/pts.0000000000000359.
https://psnet.ahrq.gov/issue/e…
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psnet.ahrq.gov/node/43039/psn-pdf
August 24, 2016 - How Doctors Think.
August 24, 2016
Groopman J. Boston, MA: Houghton Mifflin; 2007. ISBN: 0618610030.
https://psnet.ahrq.gov/issue/how-doctors-think
In this book, the author presents several stories that illustrate the forces that shape physician decision-
making and may lead to diagnostic mistakes. Borrowing from …
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psnet.ahrq.gov/node/34760/psn-pdf
March 28, 2005 - Managing the Risks of Organizational Accidents.
March 28, 2005
Reason JT. Aldershot, Hants, England: Ashgate: 1997. ISBN: 9781840141047
https://psnet.ahrq.gov/issue/managing-risks-organizational-accidents
Written 7 years after the publication of Human Error, this book demonstrates Reason's thinking at its finest
a…
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psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
June 24, 2020 - SPOTLIGHT CASE
Impatient Inpatient Dosing
Citation Text:
White RH. Impatient Inpatient Dosing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/hidden-mystery
December 01, 2011 - SPOTLIGHT CASE
Hidden Mystery
Citation Text:
Brunette DD. Hidden Mystery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - SPOTLIGHT CASE
Crossing the Line
Citation Text:
Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - SPOTLIGHT CASE
Pseudo-obstruction But a Real Perforation
Citation Text:
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
…
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psnet.ahrq.gov/node/33680/psn-pdf
March 22, 2009 - In Conversation with...Dean Schillinger, MD
March 22, 2009
In Conversation with..Dean Schillinger, MD. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
Editor's note: Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco,
Directo…
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psnet.ahrq.gov/node/33583/psn-pdf
March 01, 2023 - Simulation Training
March 1, 2023
Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/simulation-training
Originally published in 2014 by researchers at the University of California, San Francisco. Updated in
March 2023, by Jennifer J. Edwards, MS, RN, CHSE…
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Delayed Diagnosis of Mesenteric Ischemia
Source and Credits
• This presentation is based on the August 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc
o AHRQ WebM&M…
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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions
April 28, 2021
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
The Case
A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and
severe e…
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
March 27, 2024
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and
Emergency Hysterectomy. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
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psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - Hidden Mystery
March 1, 2005
Brunette DD. Hidden Mystery. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hidden-mystery
Case Objectives
Appreciate the challenges of caring for morbidly obese patients.
List specific interventions that can be implemented when caring for obese patients.
Develop a rational ap…
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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/49708/psn-pdf
May 01, 2014 - Medication Reconciliation With a Twist (or Dare We Say, a
Patch?)
May 1, 2014
Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
Case Objectives
Appreciate that medication discrepanc…
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psnet.ahrq.gov/node/33803/psn-pdf
January 01, 2015 - In Conversation With… Richard Kronick, PhD
February 1, 2014
In Conversation With… Richard Kronick, PhD. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
Editor's note: Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since
August 2013 …
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Browse Author Resources
Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging
Citation Text:
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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