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psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
January 01, 2018 - Part of the reason I'm pulling forward that neuro exam day after day or that review of systems is because
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - The reason for that is two-fold.
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Spotlight
Spotlight
Dangers of Missing an Epidural Abscess:
Multiple Visits and Delayed Diagnosis with
a Severely Negative Outcome
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Comm…
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psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
January 01, 2024 - Spotlight
Spotlight
Do Not Miss Sepsis Needles in Viral Haystacks!
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Michelle Hamline, MD, PhD, MAS and Ulfat
Shaikh, MD, M…
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psnet.ahrq.gov/node/851870/psn-pdf
July 31, 2023 - Regina Hoffman: That is our primary reason for existence—to support interorganizational learning.
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psnet.ahrq.gov/node/866622/psn-pdf
August 28, 2024 - The reason for the Safety-II
hypothesis is that most of the time, things go right despite everyday variation
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
March 24, 2025 - I think part of the reason for that is that we are not fully evolved.
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - Reason JT, Carthey J, de Leval MR.
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - In reality, the referring provider is often consumed with providing emergent care (the reason for the
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psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
January 29, 2021 - flowing over the vocal cords may trigger coughing and laryngospasm to prevent aspiration. 11 For this reason
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psnet.ahrq.gov/node/49591/psn-pdf
October 01, 2009 - wards—gave providers a clear message that
anyone suspecting that a patient is in jeopardy for any reason
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psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
June 01, 2017 - The reason for picking planned admissions was that we didn't expect the mix of patients to change very
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psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - Reason J. Human error: models and management. BMJ. 2000;320:768.
19.
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
January 01, 2024 - For this reason, patients can still frown their forehead muscles even when most other skeletal muscles
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psnet.ahrq.gov/issue/ahrq-health-literacy-universal-precautions-toolkit-0
May 26, 2010 - Toolkit
AHRQ Health Literacy Universal Precautions Toolkit. 2nd edition.
Citation Text:
Brega AG, Barnard J, Mabachi NM, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2015. AHRQ Publication No. 15-0023-EF.
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psnet.ahrq.gov/issue/decade-patient-safety-2020-2030
December 21, 2005 - Press Release/Announcement
A Decade of Patient Safety 2020-2030
Citation Text:
A Decade of Patient Safety 2020-2030. Geneva, Switzerland; World Health Organization: February 2020.
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psnet.ahrq.gov/issue/how-i-minimize-mistransfusion-risk-my-hospital
July 22, 2015 - Commentary
How I minimize mistransfusion risk in my hospital.
Citation Text:
Aubuchon JP. How I minimize mistransfusion risk in my hospital. Transfusion (Paris). 2006;46(7):1085-9.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/issue/diagnostic-errors-medicine-case-neglect
July 15, 2015 - Study
Diagnostic errors in medicine: a case of neglect.
Citation Text:
Graber ML. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2005;31(2):106-13.
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psnet.ahrq.gov/issue/could-computerization-harm-patient-safety
June 23, 2010 - Newspaper/Magazine Article
Could computerization harm patient safety?
Citation Text:
Wachter R. Could computerization harm patient safety? MedGenMed : Medscape general medicine. 2006;8(2):84.
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psnet.ahrq.gov/node/49718/psn-pdf
January 01, 2015 - Too Much, Too Fast
September 1, 2014
Tuot D. Too Much, Too Fast. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/too-much-too-fast
The Case
A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for
fever, tachycardia, and increased respiratory secretions. H…