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psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
March 07, 2012 - The blind technique is only used to obtain random liver samples and thus provides only parenchymal histology
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psnet.ahrq.gov/web-mm/worst-headache
July 01, 2016 - many false positives.( 11 ) Experimentally, CSF with red blood cell counts above 10,000 RBCs/µL or samples
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psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
December 23, 2020 - : Part 2 On further history, the medical team learned that the patient had also received multiple samples
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psnet.ahrq.gov/web-mm/unfamiliar-catheter
November 01, 2006 - familiarity with the specific type of central venous catheter (CVC) and improper technique for obtaining samples
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psnet.ahrq.gov/issue/july-effect-analysis-never-events-nationwide-inpatient-sample
November 04, 2020 - Study
Classic
The July effect: an analysis of never events in the nationwide inpatient sample.
Citation Text:
Wen T, Attenello FJ, Wu B, et al. The July effect: an analysis of never events in the nationwide inpatient sample. J Hosp Med. 2015;10(7):432-438. doi:1…
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psnet.ahrq.gov/node/43342/psn-pdf
July 16, 2014 - Prevalence and severity of patient harm in a sample of
UK-hospitalised children detected by the Paediatric
Trigger Tool.
July 16, 2014
Chapman SM, Fitzsimons J, Davey N, et al. Prevalence and severity of patient harm in a sample of UK-
hospitalised children detected by the Paediatric Trigger Tool. BMJ Open. 2014;4…
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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - reversal of specific drugs such as opiates (check pupils), benzodiazepines, anticholinergics Send blood samples
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psnet.ahrq.gov/issue/prevalence-and-severity-patient-harm-sample-uk-hospitalised-children-detected-paediatric
February 15, 2023 - Study
Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool.
Citation Text:
Chapman SM, Fitzsimons J, Davey N, et al. Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatr…
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psnet.ahrq.gov/issue/transfusion-related-errors-and-associated-adverse-reactions-and-blood-product-wastage
September 23, 2020 - Study
Transfusion-related errors and associated adverse reactions and blood product wastage as reported to the National Healthcare Safety Network Hemovigilance Module, 2014-2022.
Citation Text:
Chavez Ortiz JL, Griffin I, Kazakova SV, et al. Transfusion‐related errors and associated adve…
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psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based
April 08, 2018 - Study
Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample.
Citation Text:
Newman-Toker DE, Moy E, Valente E, et al. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-b…
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psnet.ahrq.gov/web-mm/rapid-mis-strep
February 01, 2004 - Rapid Mis-St(r)ep
Citation Text:
Kaplan EL. Rapid Mis-St(r)ep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/issue/national-incidence-medication-error-surgical-patients-and-after-accreditation-council
September 23, 2020 - Study
National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform.
Citation Text:
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients Before and Afte…
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psnet.ahrq.gov/node/33591/psn-pdf
March 15, 2025 - Triggers and Trigger Tools
March 15, 2025
Triggers and Trigger Tools. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/triggers-and-trigger-tools
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
April 17, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Diagnostic Errors Case Studies
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Created By: Maria Mirica, PRIDE Group
…
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psnet.ahrq.gov/issue/missed-diagnoses-acute-myocardial-infarction-emergency-department-variation-patient-and
April 08, 2018 - Study
Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics.
Citation Text:
Moy E, Barrett M, Coffey R, et al. Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and fa…
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - A Postpartum Woman with an Erroneous SARS-CoV-2 Test
Citation Text:
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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Forma…
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psnet.ahrq.gov/node/47379/psn-pdf
November 14, 2018 - Analysis of medication therapy discontinuation orders in
new electronic prescriptions and opportunities for
implementing CancelRx.
November 14, 2018
Yang Y, Ward-Charlerie S, Kashyap N, et al. Analysis of medication therapy discontinuation orders in new
electronic prescriptions and opportunities for implementing C…
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psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - Triggers and Trigger Tools
Citation Text:
Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/node/34734/psn-pdf
March 28, 2005 - The Definition of Quality and Approaches to Its
Assessment. Vol 1. Explorations in Quality Assessment
and Monitoring.
March 28, 2005
Donahedian A. Ann Arbor, MI; Health Administration Press: 1980. ISBN: 9780914904489.
https://psnet.ahrq.gov/issue/definition-quality-and-approaches-its-assessment-vol-1-explorations-…
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psnet.ahrq.gov/node/36364/psn-pdf
February 14, 2017 - National surveillance of emergency department visits for
outpatient adverse drug events.
February 14, 2017
Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for
outpatient adverse drug events. JAMA. 2006;296(15):1858-66.
https://psnet.ahrq.gov/issue/national-surveil…