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8681. Right Patient, Wrong Sample | PSNet
      psnet.ahrq.gov/web-mm/right-patient-wrong-sample
      June 01, 2004 - Right Patient, Wrong Sample Citation Text: Astion ML. Right Patient, Wrong Sample. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…

8682. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49735/psn-pdf
      June 01, 2015 - Anchoring Bias With Critical Implications June 1, 2015 Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications Case Objectives Appreciate that diagnostic errors are common in primary and ambulatory care. Define premature clo…

8683. Weighing In on Surgical Safety | PSNet
      psnet.ahrq.gov/web-mm/weighing-surgical-safety
      August 04, 2021 - SPOTLIGHT CASE Weighing In on Surgical Safety Citation Text: Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar …

8684. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49744/psn-pdf
      October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy October 1, 2015 Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…

8685. In Conversation With... John G. Reiling, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
      February 26, 2025 - In Conversation With... John G. Reiling, PhD December 1, 2012  Citation Text: In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012.In Conversation With... John G. Reiling, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…

8686. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866343/psn-pdf
      December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency December 31, 2024 Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hyperte…

8687. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures | PSNet
      psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
      November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures Citation Text: Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …

8688. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33607/psn-pdf
      September 27, 2022 - Burnout September 27, 2022 Yellowlees P, Rea M. Burnout. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/burnout Originally published in December 2011 by researchers at the University of California, San Francisco. Updated in September 2022 by Peter Yellowlees, MD and Margaret Rea, PhD. PSNet primers are regu…

8689. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49786/psn-pdf
      March 01, 2017 - Consequences of Medical Overuse March 1, 2017 Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/consequences-medical-overuse Case Objectives Define overuse and overdiagnosis. State how much of all care is estimated to be overuse. Describe why the likelihood…

8690. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49666/psn-pdf
      October 01, 2012 - CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure October 1, 2012 Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure Case Objectives Identify risk f…

8691. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842919/psn-pdf
      February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis. February 1, 2023 Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis The Cases Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …

8692. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49822/psn-pdf
      March 01, 2018 - Isolated Clot, Real Error March 1, 2018 Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/isolated-clot-real-error Case Objectives Appreciate that errors are common in the management of venous thromboembolism disease. Describe patients with venous thromboembolism i…

8693. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49870/psn-pdf
      August 10, 2019 - Anemia and Delayed Colon Cancer Diagnosis August 10, 2019 Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis Case Objectives Describe the initial evaluation for iron deficiency anemia in elderly adults…

8694. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49771/psn-pdf
      July 01, 2016 - Unintended Consequences of CPOE October 1, 2016 Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe Case Objectives Explain how technology, including computerized provider order entry, can transform, rather than eliminate, hazards. Recogni…

8695. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49810/psn-pdf
      November 01, 2017 - Palliative Care: Comfort vs. Harm November 1, 2017 Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm Case Objectives Recognize errors may be difficult to identify in palliative care. State that medication errors and errors in communica…

8696. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49478/psn-pdf
      April 01, 2005 - Compare and Contrast April 1, 2005 Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/compare-and-contrast Case Objectives Define contrast nephropathy (CN) List risk factors for CN Implement pharmacologic strategies for CN prophylaxis Follow an algorithm for CN risk …

8697. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49855/psn-pdf
      March 01, 2019 - Which Line: Ordering Provider or Proceduralist? March 1, 2019 Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist Case Objectives Review the role of mistake-proofing to block errors from leading to adverse…

8698. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865540/psn-pdf
      April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration April 11, 2024 Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration The Case An 82-year-old woman presented to the Emergency Department (ED) for …

8699. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49527/psn-pdf
      December 01, 2006 - Right Patient, Wrong Sample December 1, 2006 Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample The Case A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On the morning of surgery, the patien…

8700. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33837/psn-pdf
      July 01, 2017 - In Conversation With… Michelle Mello, MPhil, JD, PhD July 1, 2017 In Conversation With… Michelle Mello, MPhil, JD, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd Editor's note: Michelle Mello is Professor of Law at Stanford Law School and Professor of Healt…