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psnet.ahrq.gov/issue/origin-and-uses-primum-non-nocere-above-all-do-no-harm
January 09, 2019 - Commentary
Origin and uses of primum non nocere—above all, do no harm!
Citation Text:
Smith CM. Origin and uses of primum non nocere--above all, do no harm!. J Clin Pharmacol. 2005;45(4):371-7.
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psnet.ahrq.gov/issue/when-does-quality-improvement-count-research-human-subject-protection-and-theories-knowledge
July 10, 2019 - Commentary
When does quality improvement count as research? Human subject protection and theories of knowledge.
Citation Text:
Lynn J. When does quality improvement count as research? Human subject protection and theories of knowledge. Qual Saf Health Care. 2004;13(1):67-70.
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - SPOTLIGHT CASE
Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome
Citation Text:
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet…
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psnet.ahrq.gov/issue/communication-medical-product-risk-how-effective-effective-enough
January 17, 2007 - Review
Communication of medical product risk: how effective is effective enough?
Citation Text:
Goldman SA. Communication of medical product risk: how effective is effective enough? Drug Saf. 2004;27(8):519-34.
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Google Scholar PubMed BibTeX EndNote X3 …
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - 7, 2018
The use of human factors methods to identify and mitigate safety issues in radiation … therapy.
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - SPOTLIGHT CASE
CME/MOC
CPE
A Fatal Twist in Pseudohyperkalemia
Citation Text:
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - Delay in Appropriate Diagnosis and Treatment Leading to
Death from Pulmonary Embolism
February 10, 2021
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary
Embolism. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leadi…
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psnet.ahrq.gov/node/841305/psn-pdf
January 27, 2023 - The examples they provide are radiation therapy or blood
transfusions.
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psnet.ahrq.gov/issue/aviation-medicine-applying-concepts-aviation-safety-risk-management-ambulatory-care
June 03, 2020 - Study
From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care.
Citation Text:
Wilf-Miron R, Lewenhoff I, Benyamini Z, et al. From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care. Qual Saf Hea…
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psnet.ahrq.gov/node/49872/psn-pdf
August 08, 2019 - Spinal Epidural Abscess
August 8, 2019
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess
The Case
A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a
few days of progressive low back pain. She…
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psnet.ahrq.gov/issue/managing-risk-systems-approach-versus-personal-responsibility-hospital-incidents
November 25, 2015 - Commentary
Managing risk: systems approach versus personal responsibility for hospital incidents.
Citation Text:
Steiner JL. Managing risk: systems approach versus personal responsibility for hospital incidents. J Am Acad Psychiatry Law. 2006;34(1):96-8.
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…
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psnet.ahrq.gov/issue/engineering-risk-analysis-hospital-oxygen-supply-system
July 23, 2014 - Commentary
Engineering risk analysis of a hospital oxygen supply system.
Citation Text:
Deleris LA, Yeo GL, Seiver A, et al. Engineering risk analysis of a hospital oxygen supply system. Med Decis Making. 2006;26(2):162-72.
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psnet.ahrq.gov/node/49615/psn-pdf
December 01, 2010 - anatomical focal points including
severe kyphoscoliosis or other unusual skeletal anomalies, and previous radiation … therapy to the pelvis or
chest (Table 2).
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 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:…
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psnet.ahrq.gov/web-mm/reaction-dye
March 01, 2007 - Reaction to Dye
Citation Text:
Cohan R. Reaction to Dye. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - SPOTLIGHT CASE
Dangerous Dialysis
Citation Text:
Holley JL. Dangerous Dialysis . 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/node/838855/psn-pdf
October 27, 2022 - False Assumptions Result in a Missed Pneumothorax
after Bronchoscopy with Transbronchial Biopsy.
October 27, 2022
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy
with Transbronchial Biopsy. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
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psnet.ahrq.gov/web-mm/forgotten-turn
August 01, 2018 - anatomical focal points including severe kyphoscoliosis or other unusual skeletal anomalies, and previous radiation … therapy to the pelvis or chest ( Table 2 ).
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - SPOTLIGHT CASE
CME/MOC
False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.
Citation Text:
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet…