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psnet.ahrq.gov/issue/free-harm-accelerating-patient-safety-improvement-fifteen-years-after-err-human
November 15, 2016 - Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires
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psnet.ahrq.gov/issue/our-pharmacy-meeting-patients-needs-pharmacy-health-literacy-assessment-tool-users-guide
December 24, 2008 - March 27, 2018
FDA Drug Safety Communication: FDA requires labeling changes for prescription
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psnet.ahrq.gov/issue/iv-push-medications-survey-results-part-1-and-part-2
December 12, 2018 - July 18, 2018
Safety with nebulized medications requires an interdisciplinary team approach
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psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm
June 21, 2016 - Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires
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psnet.ahrq.gov/issue/closing-loop-guide-safer-ambulatory-referrals-ehr-era
July 12, 2017 - Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires
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psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
March 01, 2012 - And to understand that requires you to really understand the circumstances.
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psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
March 01, 2012 - And to understand that requires you to really understand the circumstances.
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - It’s important to see that systems need to be engineered and designed, and that requires special skills
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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…
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - Missing Trauma
Citation Text:
Jurkovich GJ. Missing Trauma. 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/web-mm/say-it-again
January 31, 2020 - Say It Again
Citation Text:
Henriksen K, Hall KK. Say It Again. 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/obstructed-view
August 07, 2019 - An Obstructed View
Citation Text:
Carter J. An Obstructed View. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/chest-tube-complications
September 27, 2023 - Chest Tube Complications
Citation Text:
Santhosh L, Broaddus C. Chest Tube Complications. 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/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/painful-dilemma
September 01, 2013 - A Painful Dilemma
Citation Text:
Davison SN. A Painful Dilemma. 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/node/49638/psn-pdf
January 01, 2012 - Communication Failure—Who's in Charge?
October 1, 2011
Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge
The Case
A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu…
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psnet.ahrq.gov/perspective/context-intervention
August 05, 2020 - The Context Is the Intervention
Dr. John Øvretveit | October 1, 2011
View more articles from the same authors.
Citation Text:
Øvretveit J. The Context Is the Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
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psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
April 24, 2024 - Right Electrocardiogram, Wrong Patient
Citation Text:
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. 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/lapse-antibiotics-leads-sepsis
November 21, 2021 - Lapse in Antibiotics Leads to Sepsis
Citation Text:
Levy MM. Lapse in Antibiotics Leads to Sepsis. 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/node/49458/psn-pdf
September 01, 2004 - Poor Prognosis
September 1, 2004
Lamont EB. Poor Prognosis. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/poor-prognosis
Case Objectives
Understand the current limitations of physicians' ability to provide prognoses.
List the variables that can be used to guide treatment decisions and prognostication in e…