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psnet.ahrq.gov/perspective/overuse-patient-safety-problem
September 01, 2014 - RW : When you talk to practicing physicians about overuse they have almost an inkblot response.
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psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - In response to this error, improved processes which incorporate end-user input and feedback should be
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - crowded EDs minimize harm
and reduce delays for patients who wait for bed placement:
– Pull until full
– Rapid
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psnet.ahrq.gov/web-mm/slippery-slide-life
January 21, 2017 - Slippery Slide Into Life
Citation Text:
Halamek LP. Slippery Slide Into Life. 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 tagged …
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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - The "5Es" of emergency physician-performed focused
cardiac ultrasound: a protocol for rapid identification
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - July 30, 2008
WebM&M Cases
Rapid Mis-St(r)ep
February
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psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
December 01, 2017 - One of the ironies of the rapid adoption of EHR technology in the United States is that clinicians can
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - bypasses the multi-level safety checks otherwise implemented in the hospital setting. 3,4,5 In addition, rapid
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - this case an ileostomy, may make it difficult to predict the
location of bleeding because of more rapid
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psnet.ahrq.gov/node/49582/psn-pdf
April 01, 2009 - Breakage of a PICC Line
April 1, 2009
Dimov V. Breakage of a PICC Line. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/breakage-picc-line
Case Objectives
Appreciate the incidence and consequences of PICC line breakage.
Understand the risk factors for PICC line breakage.
Understand the treatment options in…
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psnet.ahrq.gov/web-mm/too-much-too-fast
June 14, 2019 - As this case illustrates, rapid administration of potassium can be dangerous, even among patients with
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psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - While these the guidelines were well-intentioned and geared toward improving opioid stewardship, rapid
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psnet.ahrq.gov/node/49783/psn-pdf
February 01, 2017 - may gradually be losing the ability to read and think in depth about an issue,
causing us to jump to rapid
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psnet.ahrq.gov/web-mm/poor-prognosis
March 15, 2016 - SPOTLIGHT CASE
Poor Prognosis
Citation Text:
Lamont EB. Poor Prognosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
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psnet.ahrq.gov/node/33773/psn-pdf
September 01, 2014 - Overuse as a Patient Safety Problem
September 1, 2014
Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem
Perspective
Nearly half of primary care physicians in the United States believe that patients cared for in their own
prac…
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psnet.ahrq.gov/node/857060/psn-pdf
November 27, 2023 - Patient safety competencies in undergraduate nursing
students: a rapid evidence assessment.
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psnet.ahrq.gov/node/49628/psn-pdf
June 01, 2011 - Routine Goes Awry
June 1, 2011
Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/routine-goes-awry
The Case
A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and
scheduled for a tonsillectomy and adenoidectomy. She was in ot…
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psnet.ahrq.gov/node/49551/psn-pdf
December 01, 2007 - Too Hot For Comfort
December 1, 2007
Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/too-hot-comfort
The Case
A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV
antibiotics via a peripheral line in the left antec…
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psnet.ahrq.gov/node/33727/psn-pdf
March 01, 2012 - Can Research Help Us Improve the Medical Liability
System?
March 1, 2012
Kachalia A. Can Research Help Us Improve the Medical Liability System? PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
Perspective
The United States medical malpractice liabili…
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psnet.ahrq.gov/node/49487/psn-pdf
August 21, 2005 - Surprise Wire
August 21, 2005
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/surprise-wire
The Case
A 39-year-old man with a history of liver disease presented to the emergency department (ED) with
gastrointestinal bleeding and altered mental status. Due to his clinic…