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psnet.ahrq.gov/node/43088/psn-pdf
February 25, 2019 - ImproveDX.
February 25, 2019
Society to Improve Diagnosis in Medicine.
https://psnet.ahrq.gov/issue/improvedx
Diagnostic errors have been termed the next frontier in patient safety. To raise awareness of this issue, this
occasional newsletter features articles for a multidisciplinary audience that discuss barriers…
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psnet.ahrq.gov/primer/electronic-health-records
March 15, 2025 - Electronic Health Records
Citation Text:
Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/web-mm/x-ray-flip
August 10, 2019 - X-ray Flip
Citation Text:
Shapiro MJ. X-ray Flip. 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 tagged PubMedId RIS
Downl…
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psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - Hold the tPA
Citation Text:
Fagan SC. Hold the tPA. 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 PubMedId RIS
Dow…
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psnet.ahrq.gov/node/865698/psn-pdf
April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges
April 24, 2024
Leary KB, Lee M, Mossburg S. Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
Introduction
Nurses are essential to patient care, and having a…
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psnet.ahrq.gov/node/49521/psn-pdf
September 12, 2006 - A Troubling Amine
September 1, 2006
Flynn EA. A Troubling Amine. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/troubling-amine
The Case
A 43-year-old woman was admitted to the intensive care unit for symptoms of heart and respiratory failure.
She was found to have severe mitral and tricuspid valve regurgi…
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psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx
Spotlight
When the Indications for Drug
Administration Blur
Source and Credits
• This presentation is based on the June 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Julia Munsch,…
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psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - Milliliters vs. Milligrams
December 1, 2010
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
The Case
A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His
evaluation showed acu…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/49589/psn-pdf
August 01, 2009 - Hiding in Plain Sight
August 1, 2009
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/hiding-plain-sight
The Case
A 65-year-old woman presented to an emergency department (ED) with 48 hours of nontraumatic left lower
back pain and general malaise. She was diagnosed with a …
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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - December 22, 2009
Color coded medication safety system reduces community pediatric emergency
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psnet.ahrq.gov/web-mm/consequences-medical-overuse
May 05, 2021 - Clinical decision support reduces overuse of red blood cell transfusions: interrupted time series analysis
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - Poor adherence, which reduces the chances of successful treatment, has been reported among selected populations
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - Combining this standard practice with barcode scanning significantly reduces laboratory
testing errors
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - 5 This patient was intubated with a McGrath laryngoscope, which is a video-laryngoscope that also reduces
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psnet.ahrq.gov/node/49750/psn-pdf
January 01, 2016 - nursing care including medication administration.(12) Medication reconciliation at the
time of admission reduces
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psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - Standardized ordering and administration of total parenteral
nutrition reduces errors in children's
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psnet.ahrq.gov/node/49721/psn-pdf
December 01, 2014 - Simulation-based mastery learning
reduces complications during central venous catheter insertion in
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psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
January 01, 2024 - dependent upon an
elaborate annular and cruciate pulley system that multiplies mechanical forces, reduces
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psnet.ahrq.gov/node/861738/psn-pdf
January 31, 2024 - dependent upon an elaborate annular and cruciate
pulley system that multiplies mechanical forces, reduces