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psnet.ahrq.gov/node/49414/psn-pdf
September 01, 2003 - this case, since the patient experienced postmenopausal bleeding,
thorough inspection and endometrial sampling
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psnet.ahrq.gov/node/38417/psn-pdf
February 18, 2009 - Enhanced detection of blood bank sample collection
errors with a centralized patient database.
February 18, 2009
MacIvor D, Triulzi DJ, Yazer MH. Enhanced detection of blood bank sample collection errors with a
centralized patient database. Transfusion (Paris). 2009;49(1):40-3. doi:10.1111/j.1537-2995.2008.01923.x.…
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psnet.ahrq.gov/issue/evaluating-sample-medications-primary-care-practice-based-research-network-study
July 12, 2010 - Study
Evaluating sample medications in primary care: a practice-based research network study.
Citation Text:
Hansen LB, Saseen JJ, Westfall JM, et al. Evaluating sample medications in primary care: a practice-based research network study. Jt Comm J Qual Patient Saf. 2006;32(12):688-692…
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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/node/40873/psn-pdf
November 26, 2014 - Inappropriate medication in a national sample of US
elderly patients receiving home health care.
November 26, 2014
Bao Y, Shao H, Bishop TF, et al. Inappropriate medication in a national sample of US elderly patients
receiving home health care. J Gen Intern Med. 2012;27(3):304-310. doi:10.1007/s11606-011-1905-4.
h…
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psnet.ahrq.gov/node/44713/psn-pdf
January 20, 2016 - Are surgeons and anesthesiologists lying to each other or
gaming the system? A national random sample survey
about "truth-telling practices" in the perioperative setting
in the United States.
January 20, 2016
Nurok M, Lee Y-Y, Ma Y, et al. Are surgeons and anesthesiologists lying to each other or gaming the
syste…
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psnet.ahrq.gov/node/49421/psn-pdf
October 01, 2003 - Urine a Tough Position
October 1, 2003
Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/urine-tough-position
The Case
A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although
she did not want to have a baby at that time, she sta…
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psnet.ahrq.gov/node/50949/psn-pdf
February 26, 2020 - Pre-analytical pitfalls: Missing and mislabeled specimens
February 26, 2020
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
The Case
Case #1:
A 56-year-old man was admitted to…
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psnet.ahrq.gov/node/37672/psn-pdf
April 09, 2008 - An observational study of laterality errors in a sample of
clinical records.
April 9, 2008
Elghrably I, Fraser SG. An observational study of laterality errors in a sample of clinical records. Eye
(Lond). 2008;22(3):340-3.
https://psnet.ahrq.gov/issue/observational-study-laterality-errors-sample-clinical-records
C…
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psnet.ahrq.gov/node/44064/psn-pdf
November 03, 2015 - The July effect: an analysis of never events in the
nationwide inpatient sample.
November 3, 2015
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:10.1002/jhm.2352.
https://psnet.ahrq.gov/issue/july-effect-analysi…
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psnet.ahrq.gov/issue/patients-admitted-weekends-have-higher-hospital-mortality-those-admitted-weekdays-analysis
January 26, 2022 - Study
Patients admitted on weekends have higher in-hospital mortality than those admitted on weekdays: analysis of national inpatient sample.
Citation Text:
Manadan A, Arora S, Whittier M, et al. Patients admitted on weekends have higher in-hospital mortality than those admitted on weekd…
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psnet.ahrq.gov/web-mm/urine-tough-position
January 01, 2009 - Urine a Tough Position
Citation Text:
Gandhi TK. Urine a Tough Position. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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psnet.ahrq.gov/issue/enhanced-detection-blood-bank-sample-collection-errors-centralized-patient-database
March 20, 2019 - Study
Enhanced detection of blood bank sample collection errors with a centralized patient database.
Citation Text:
MacIvor D, Triulzi DJ, Yazer MH. Enhanced detection of blood bank sample collection errors with a centralized patient database. Transfusion (Paris). 2009;49(1):40-3. doi:…
-
psnet.ahrq.gov/node/60273/psn-pdf
April 29, 2020 - Potential preanalytical and analytical vulnerabilities in the
laboratory diagnosis of coronavirus disease 2019 (COVID-
19).
April 29, 2020
Lippi G, Simundic A-M, Plebani M. Potential preanalytical and analytical vulnerabilities in the laboratory
diagnosis of coronavirus disease 2019 (COVID-19). Clin Chem Lab Med. …
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near-
Miss Wrong Transfusion Event
January 29, 2020
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens
Citation Text:
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citation
Format:
…
-
psnet.ahrq.gov/node/849596/psn-pdf
May 31, 2023 - Patients admitted on weekends have higher in-hospital
mortality than those admitted on weekdays: analysis of
national inpatient sample.
May 31, 2023
Manadan A, Arora S, Whittier M, et al. Patients admitted on weekends have higher in-hospital mortality
than those admitted on weekdays: analysis of national inpatient…
-
psnet.ahrq.gov/node/34719/psn-pdf
December 23, 2008 - Learning from samples of one or fewer.
December 23, 2008
March JG, Sproull LS, Tamuz M. Org Sci.1991;2:1-13. (reprinted in: Qual Saf Health Care 2003;12:465-
472.)
https://psnet.ahrq.gov/issue/learning-samples-one-or-fewer
Organizations learn from experience. However, learning from rare events is challenging becau…
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psnet.ahrq.gov/node/43720/psn-pdf
November 26, 2014 - Hamilton father misdiagnosed with lung cancer demands
answers.
November 26, 2014
Carville O. The Star. November 14, 2014.
https://psnet.ahrq.gov/issue/hamilton-father-misdiagnosed-lung-cancer-demands-answers
This news article reports on a case involving a patient who was misdiagnosed with terminal cancer and
touc…
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…