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psnet.ahrq.gov/periodic-issue/periodic-issue-472
February 26, 2025 - February 26, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, repor…
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
September 15, 2025 - Breadcrumb
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Diagnostic Errors Case Studies
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Created By: Maria Mirica, PRIDE Group
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psnet.ahrq.gov/web-mm/paradoxical-pulse
May 01, 2013 - Paradoxical Pulse
Citation Text:
Roy CL. Paradoxical Pulse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
August 06, 2014 - Delayed Clozapine Prescription in an Elderly Man With Dementia
Citation Text:
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - Inadvertent Castration
Citation Text:
Calland FJ. Inadvertent Castration. 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/turn-other-cheek
October 26, 2010 - Turn the Other Cheek
Citation Text:
Starling J. Turn the Other Cheek. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
February 26, 2025 - “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV)
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June 30, 2021
Innovat…
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psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA
December 1, 2006
Also Read an Essay
Citation Text:
In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006.In Conversation with...J. Bryan Sexton, PhD, MA. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - A Statewide Collaborative to Support Vaginal Birth and
Reduce Unnecessary Cesarean Deliveries
July 8, 2022
https://psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-
cesarean-deliveries
Summary
Started in response to rising maternal morbidity and mortality rates in …
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psnet.ahrq.gov/node/72586/psn-pdf
December 23, 2020 - Code Status vs. Care Status
December 23, 2020
Krisman RK, Spero H. Code Status vs. Care Status. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/code-status-vs-care-status
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for
Continuing Medical Education (AC…
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - Establishing a Safety Culture: Thinking Small
Timothy J. Hoff, PhD | December 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. Rockville (MD): Age…
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psnet.ahrq.gov/node/49399/psn-pdf
May 01, 2003 - Ectopic or Not?
May 1, 2003
Givens VM, Lipscomb GH. Ectopic or Not? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/ectopic-or-not
The Case
The patient is a 24-year-old woman, gravida 4, para 1, ectopic 1, at 6 weeks from her last menstrual period.
She presents to the emergency department with a 3-day histo…
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psnet.ahrq.gov/web-mm/transfusion-slip
June 14, 2011 - Transfusion "Slip"
Citation Text:
Kaplan HS. Transfusion "Slip". 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/dropped-lung
February 06, 2012 - The Dropped Lung
Citation Text:
Heffner JR. The Dropped Lung. 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/milliliters-vs-milligrams
September 01, 2004 - Milliliters vs. Milligrams
Citation Text:
Poole RL, Dixon T. Milliliters vs. Milligrams. 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/838972/psn-pdf
October 27, 2022 - The Unhappy Patient Leaves Against Medical Advice.
October 27, 2022
Nichols A. The Unhappy Patient Leaves Against Medical Advice. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
The Case
A 61-year-old woman was placed on bedrest following major surgery. Her posto…
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psnet.ahrq.gov/web-mm/two-pills-same-drug
May 27, 2011 - Two Pills, Same Drug
Citation Text:
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - The Forgotten Radiographic Read
Citation Text:
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/hiding-plain-sight
April 24, 2019 - Hiding in Plain Sight
Citation Text:
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - Getting the Diagnosis Both Right and Wrong
September 25, 2019
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
The Case
A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…