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psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
August 21, 2005 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism.
Citation Text:
Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - Medication Administration Errors
Citation Text:
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - Personal Health Literacy
Citation Text:
Bakerjian D. Personal Health Literacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care
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December 23, 2020
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psnet.ahrq.gov/web-mm/emergency-error
January 18, 2013 - SPOTLIGHT CASE
Emergency Error
Citation Text:
Symons NRA. Emergency Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - SPOTLIGHT CASE
Missed Appendicitis
Citation Text:
Adams JG. Missed Appendicitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - Personal Health Literacy
August 30, 2023
Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/personal-health-literacy
Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in
August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
Citation Text:
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/web-mm/code-status-confusion
September 01, 2006 - SPOTLIGHT CASE
Code Status Confusion
Citation Text:
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/autopsy-revelation
December 01, 2007 - Autopsy Revelation
Citation Text:
Shojania KG. Autopsy Revelation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/worst-headache
July 01, 2016 - The Worst Headache
Citation Text:
Edlow JA. The Worst Headache. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - Medication Mix-Up Leads to Patient Death
November 30, 2023
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
The Case
An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
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psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - Root Cause Analysis Gone Wrong
May 1, 2018
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
The Case
A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney
transplant. A suitabl…
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - SPOTLIGHT CASE
The Wrong Shot: Error Disclosure
Citation Text:
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/850675/psn-pdf
June 14, 2023 - Patient and Family Roles in Safety
June 14, 2023
Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety
Moving From Engagement to Partnership
Involving patients and families in healthcare decisions about patient c…
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psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure
to Rescue after Limited Response to Nursing Concerns.
July 10, 2024
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response
to Nursing Concerns. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hemorrhagic-sh…
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psnet.ahrq.gov/node/72563/psn-pdf
December 07, 2020 - In Conversation With... Katie J. Suda, PharmD, MS
December 7, 2020
In Conversation With.. Katie J. Suda, PharmD, MS . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
Editor’s Note: Katie J. Suda, PharmD, MS is a professor at the University of Pittsburgh School of Medic…
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psnet.ahrq.gov/node/33637/psn-pdf
August 01, 2006 - In Conversation with...Lucian Leape, MD
August 1, 2006
In Conversation with..Lucian Leape, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: What kind of career did you fashion for yourself prior to
getting involved in safety an…
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psnet.ahrq.gov/node/49600/psn-pdf
April 01, 2010 - Bad Writing, Wrong Medication
April 1, 2010
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
Case Objectives
Differentiate between a medication error and an adverse drug event.
Appreciate the system complexities involved in medication erro…
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.
Citation Text:
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…