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psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
May 01, 2017 - Wrong Turn through Colon: Misplaced PEG
Citation Text:
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. 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/pathologic-mistake
February 15, 2010 - Pathologic Mistake
Citation Text:
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/node/49461/psn-pdf
September 01, 2004 - Reaction to Dye
September 1, 2004
Cohan R. Reaction to Dye. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/reaction-dye
The Case
A patient was referred to urology after having several episodes of gross hematuria. The urologist thought
that the patient might have a renal mass and sent him to radiology for a…
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psnet.ahrq.gov/periodic-issue/periodic-issue-306
August 25, 2021 - August 25, 2021 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, reports…
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psnet.ahrq.gov/periodic-issue/periodic-issue-313
October 27, 2021 - October 13, 2021 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, report…
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psnet.ahrq.gov/periodic-issue/periodic-issue-349
July 08, 2022 - July 6, 2022 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, reports, a…
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psnet.ahrq.gov/periodic-issue/periodic-issue-395
June 28, 2023 - June 14, 2023 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, reports, …
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psnet.ahrq.gov/periodic-issue/periodic-issue-432
March 27, 2024 - March 20, 2024 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, reports,…
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psnet.ahrq.gov/node/49705/psn-pdf
January 01, 2020 - A "Reflexive" Diagnosis in Primary Care
April 1, 2014
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
Case Objectives
Appreciate that primary care doctors may be caring for an increasing number of patients wi…
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psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
September 15, 2024 - COVID-19: Team and Human Factors to Improve Safety
Citation Text:
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. 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/perspective/are-we-getting-better-measuring-patient-safety
November 10, 2015 - Are We Getting Better at Measuring Patient Safety?
Amy K. Rosen, PhD | November 1, 2010
View more articles from the same authors.
Citation Text:
Rosen AK. Are We Getting Better at Measuring Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare R…
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psnet.ahrq.gov/web-mm/language-barrier
February 28, 2024 - Language Barrier
Citation Text:
Flores G. Language Barrier. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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…
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psnet.ahrq.gov/web-mm/central-line-clot
August 04, 2021 - SPOTLIGHT CASE
Central Line Clot
Citation Text:
Randolph AG. Central Line Clot. 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/watch-warfarin
December 01, 2013 - SPOTLIGHT CASE
Watch the Warfarin!
Citation Text:
Khanna R, Fang MC. Watch the Warfarin!. 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/node/74251/psn-pdf
January 26, 2022 - Delayed Diagnosis and Treatment of an Occult
Hemothorax Following Complicated Central Line Insertion
Leads to Cardiac Arrest
January 26, 2022
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated
Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022.
https…
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic
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April 27, 2022
Innovation
Conta…
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - Coming Undone: Failure of Closure Device
Citation Text:
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/49508/psn-pdf
January 01, 2007 - Language Barrier
April 1, 2006
Flores G. Language Barrier. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/language-barrier
The Case
A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish-
speaking parents when they noted that their daughter had generalized we…
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psnet.ahrq.gov/web-mm/reaction-dye
March 01, 2007 - Reaction to Dye
Citation Text:
Cohan R. Reaction to Dye. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Medication Mix-Up: From Bad to Worse
Citation Text:
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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