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4201. Poor Prognosis | PSNet
      psnet.ahrq.gov/web-mm/poor-prognosis
      March 15, 2016 - SPOTLIGHT CASE Poor Prognosis Citation Text: Lamont EB. Poor Prognosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…

4202. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49687/psn-pdf
      August 21, 2013 - Emergency Error August 21, 2013 Symons NRA. Emergency Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/emergency-error Case Objectives State that emergency surgery is high risk and has high mortality. Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of …

4203. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72834/psn-pdf
      March 10, 2021 - Approach to Improving Patient Safety: Communication March 10, 2021 Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication Introduction Each one of the countless necessa…

4204. Abdominal Aortic Aneurysm Screening | PSNet
      psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
      October 01, 2011 - SPOTLIGHT CASE Abdominal Aortic Aneurysm Screening Citation Text: Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX E…

4205. Departure From Central Line Ritual | PSNet
      psnet.ahrq.gov/web-mm/departure-central-line-ritual
      October 13, 2018 - Departure From Central Line Ritual Citation Text: Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndN…

4206. Reconciling Doses | PSNet
      psnet.ahrq.gov/web-mm/reconciling-doses
      August 14, 2017 - SPOTLIGHT CASE Reconciling Doses Citation Text: Federico F. Reconciling Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

4207. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49789/psn-pdf
      April 01, 2017 - Engaging Seriously Ill Older Patients in Advance Care Planning April 1, 2017 Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning Case Objectives Define advance care planning an…

4208. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865984/psn-pdf
      May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. May 29, 2024 Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D- dimer. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d…

4209. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49762/psn-pdf
      June 01, 2016 - The Case of Mistaken Intubation June 1, 2016 Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/case-mistaken-intubation Case Objectives Appreciate that most older adults and many younger chronically ill patients have discussed or documented their preferences for l…

4210. Wandering Off the Floors: Safety and Security Risks of Patient Wandering | PSNet
      psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
      August 21, 2007 - SPOTLIGHT CASE Wandering Off the Floors: Safety and Security Risks of Patient Wandering Citation Text: Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Huma…

4211. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49795/psn-pdf
      June 01, 2017 - The Perils of Contrast Media June 1, 2017 Sadat U, Solomon R. The Perils of Contrast Media. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/perils-contrast-media Case Objectives Recognize that contrast media are potentially nephrotoxic. Identify key risk factors for the development of contrast-induced kidne…

4212. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49780/psn-pdf
      January 01, 2017 - The Missing Abscess: Radiology Reads in the Digital Era January 1, 2017 Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era Case Objectives Identify the most common complication of hysterectomy. Descr…

4213. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33596/psn-pdf
      June 01, 2025 - Failure to Rescue January 29, 2025 Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/failure-rescue Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet primers are regularly reviewed and updated to ensure that they reflect cur…

4214. The Wrong Channel | PSNet
      psnet.ahrq.gov/web-mm/wrong-channel
      February 01, 2003 - The Wrong Channel Citation Text: Gosbee JW. The Wrong Channel . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

4215. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49445/psn-pdf
      May 01, 2004 - No Blood, Please May 1, 2004 Liang BA. No Blood, Please. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/no-blood-please The Case A young woman, about 30 years of age, was injured in an automobile collision. She was brought to the emergency department (ED) via ambulance, where she was found to be suffering …

4216. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33609/psn-pdf
      March 15, 2025 - Clinical Decision Support Systems March 15, 2025 Clinical Decision Support Systems. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/clinical-decision-support-systems PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice…

4217. Patient Safety in Office-Based Care Settings | PSNet
      psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
      January 31, 2024 - Addressing the gaps in quality and safety in primary care requires interprofessional quality improvement

4218. Building a Safety Program in a Vast Health Care Network | PSNet
      psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
      March 01, 2019 - It also requires tremendous attention to information flow in both directions—from the center to the local

4219. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units | PSNet
      psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
      April 26, 2023 - It’s important to see that systems need to be engineered and designed, and that requires special skills

4220. In Conversation With… Abraham Verghese, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-abraham-verghese-md
      November 01, 2012 - Restoring physical diagnosis to its proper place in clinical medicine requires two types of changes.