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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and
Umpires Have in Common?
February 1, 2007
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
Perspectiv…
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psnet.ahrq.gov/node/33592/psn-pdf
December 15, 2024 - Adverse Events, Near Misses, and Errors
December 15, 2024
Adverse Events, Near Misses, and Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current re…
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psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
May 19, 2021 - SPOTLIGHT CASE
Postdischarge Follow-Up Phone Call
Citation Text:
Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. 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/web-mm/when-patients-and-providers-speak-different-languages
December 08, 2021 - SPOTLIGHT CASE
When Patients and Providers Speak Different Languages
Citation Text:
Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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…
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psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - In Conversation With… Tejal K. Gandhi, MD, MPH
April 1, 2014
Citation Text:
In Conversation With… Tejal K. Gandhi, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - Missed Opportunities for Suicide Risk Assessment
November 27, 2019
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…
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psnet.ahrq.gov/node/49831/psn-pdf
June 01, 2018 - Chest Pain in a Rural Hospital
June 1, 2018
MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
Case Objectives
Recognize that a significant proportion of the Unites States population receives care in rural safety
net emergency dep…
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - SPOTLIGHT CASE
Suicidal Ideation in the Family Medicine Clinic
Citation Text:
Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
January 29, 2021 - Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.
Citation Text:
Bohringer C. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.. PSNet [internet]. Rockville (MD): Agency for He…
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - SPOTLIGHT CASE
Multifactorial Medication Mishap
Citation Text:
Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
February 01, 2004 - SPOTLIGHT CASE
Delay in Treatment: Failure to Contact Patient Leads to Significant Complications
Citation Text:
Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…
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psnet.ahrq.gov/node/846169/psn-pdf
March 15, 2023 - Distraction of the Anesthesiologist and Lack of
Resuscitation Drugs Resulting in Delayed Treatment of
Laryngospasm.
March 15, 2023
Bohringer C. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed
Treatment of Laryngospasm. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/…
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - Delayed Breast Cancer Diagnosis: A False Sense of Security.
Citation Text:
Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
June 02, 2021 - SPOTLIGHT CASE
Chest Pain in a Rural Hospital
Citation Text:
MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - SPOTLIGHT CASE
Crushing Chest Pain: A Missed Opportunity
Citation Text:
Graber ML. Crushing Chest Pain: A Missed Opportunity. 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/46723/psn-pdf
April 12, 2019 - Diagnostic assessment of deep learning algorithms for
detection of lymph node metastases in women with
breast cancer.
April 12, 2019
Bejnordi BE, Veta M, van Diest PJ, et al. Diagnostic Assessment of Deep Learning Algorithms for Detection
of Lymph Node Metastases in Women With Breast Cancer. JAMA. 2017;318(22):219…
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psnet.ahrq.gov/node/37417/psn-pdf
March 28, 2012 - Medication use leading to emergency department visits
for adverse drug events in older adults.
March 28, 2012
Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for
adverse drug events in older adults. Ann Intern Med. 2007;147(11):755-765.
https://psnet.ahrq.gov/issue/med…
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psnet.ahrq.gov/node/46098/psn-pdf
July 24, 2017 - Prospective evaluation of a multifaceted intervention to
improve outcomes in intensive care: the Promoting
Respect and Ongoing Safety through Patient Engagement
Communication and Technology study.
July 24, 2017
Dykes PC, Rozenblum R, Dalal A, et al. Prospective Evaluation of a Multifaceted Intervention to Improve
…
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psnet.ahrq.gov/node/43664/psn-pdf
September 01, 2016 - Insights into the problem of alarm fatigue with
physiologic monitor devices: a comprehensive
observational study of consecutive intensive care unit
patients.
September 1, 2016
Drew BJ, Harris P, Zègre-Hemsey JK, et al. Insights into the problem of alarm fatigue with physiologic
monitor devices: a comprehensive ob…
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psnet.ahrq.gov/node/46851/psn-pdf
January 23, 2019 - To care is human—collectively confronting the clinician-
burnout crisis.
January 23, 2019
Dzau VJ, Kirch DG, Nasca TJ. To Care Is Human — Collectively Confronting the Clinician-Burnout Crisis.
New Engl J Med. 2018;378(4):312-314. doi:10.1056/nejmp1715127.
https://psnet.ahrq.gov/issue/care-human-collectively-confro…