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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - Learning Objectives Explain general approaches for treating hypotension in the ICU Recognize risks associated
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psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - SPOTLIGHT CASE
Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees
Citation Text:
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/node/49753/psn-pdf
February 01, 2016 - Robotic Surgery: Risks vs. Rewards
February 1, 2016
Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
Case Objectives
Discuss the background and current trends in robotic surgery.
Identify the benefits of robotic s…
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - Syringe Swap During Regional Block: A Case of
Medication Error and Recovery
January 31, 2024
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…
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psnet.ahrq.gov/node/838900/psn-pdf
October 27, 2022 - Fecal Contamination of the Peritoneum from
Laparoscopic Trocar Injury: A Routine Operation Goes
Wrong.
October 27, 2022
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine
Operation Goes Wrong. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/fecal-contamination-…
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - Challenges of Diabetes Management and Medication
Reconciliation
August 5, 2022
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
The Cases
Case #1: A 53-year-old man …
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psnet.ahrq.gov/curated-library/diagnostic-safety-improvement
July 21, 2025 - Breadcrumb
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Diagnostic Safety Improvement
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNe…
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psnet.ahrq.gov/print/pdf/node/854855
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Patient as a Team Member in Clinical Care
Curated Library
Foundations
Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving
Patient Safety.
Kendir C, Fujisawa R, Brito Fernandes O, et al. Paris, F…
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psnet.ahrq.gov/curated-library/patient-team-member-clinical-care
March 15, 2025 - Breadcrumb
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Created By: Lorri Zipperer, Cybraria…
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psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - SPOTLIGHT CASE
Triple Handoff
Citation Text:
Vidyarthi A. Triple Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/web-mm/picture-speaks-1000-words
July 16, 2015 - The adverse event was not due to a resident's failure to recognize certain pathology or the risk that … this light, workarounds might be considered comparable to a "near miss," that is, an opportunity to recognize
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psnet.ahrq.gov/node/43900/psn-pdf
February 11, 2015 - Once easily recognized, signs of measles now elude
young doctors.
February 11, 2015
Brown E, Lin RG II R, Xia R. Los Angeles Times. January 26, 2015.
https://psnet.ahrq.gov/issue/once-easily-recognized-signs-measles-now-elude-young-doctors
In light of the recent outbreak of measles in California, this newspaper ar…
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psnet.ahrq.gov/node/33690/psn-pdf
December 01, 2009 - Therefore, whenever an "event" is
reported, we recognize that there may be two sides to the story. … They recognize the tiered
intervention process. … All of us need to recognize that disclosure is neither an
event nor a moment in time but a process.
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psnet.ahrq.gov/node/49484/psn-pdf
June 01, 2005 - did not automatically cancel the other, free-form
orders, a processing issue the intern failed to recognize … Although an expert physician may instantly recognize the danger of ordering this drug
combination, the
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.212_slideshow.ppt
February 01, 2010 - Teen Pregnancy (2)
Teenagers are less likely to recognize or acknowledge pregnancy
In one hospital, … about local resources related to adolescent sexual health
Adolescents are less likely than adults to recognize
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psnet.ahrq.gov/node/49427/psn-pdf
January 01, 2004 - critical
issues before plowing forward with a planned procedure or therapy—lead clinicians to fail to recognize … Combating cognitive errors and supporting situation awareness
requires procedures and systems that recognize
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psnet.ahrq.gov/node/49734/psn-pdf
May 01, 2015 - The proceduralist opened a second kit, making it more difficult to assess for and recognize
missing … A second team member—and this need not be a physician—might have
helped recognize the implication of
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psnet.ahrq.gov/web-mm/xl-or-smaller
September 13, 2017 - The pediatric intern had minimal experience dealing with hypertensive medications, and did not recognize … other checkpoints along the way (ie, the dispensing and administration of the drug) failed either to recognize
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psnet.ahrq.gov/node/49797/psn-pdf
June 01, 2017 - To overcome it,
providers must:
Recognize that it exists and can adversely impact their ability to … accurate history when caring for frequent ED users and those
with behavioral health diagnoses and to recognize
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psnet.ahrq.gov/webmm/submit-case
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