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psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
May 31, 2023 - The worst-case scenario is when you implement the EHR, because of the inertia and the fact that nobody
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - the most common diagnosis, the most dangerous diagnosis (also known as ROWS, or “Rule Out Worst
Case Scenario
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psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd
February 01, 2006 - multi-factorial they often are, one thing that surprised me was how there is a nugget in virtually every scenario
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psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
February 01, 2006 - multi-factorial they often are, one thing that surprised me was how there is a nugget in virtually every scenario
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psnet.ahrq.gov/node/33791/psn-pdf
September 01, 2015 - The worst-
case scenario is when you implement the EHR, because of the inertia and the fact that nobody
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psnet.ahrq.gov/periodic-issue/periodic-issue-294
June 30, 2021 - June 2, 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, a…
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format: …
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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - SPOTLIGHT CASE
Cognitive Overload in the ICU
Citation Text:
Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTe…
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psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
January 29, 2021 - Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.
Citation Text:
Bohringer C. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.. PSNet [internet]. Rockville (MD): Agency for He…
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psnet.ahrq.gov/node/33878/psn-pdf
April 01, 2019 - In Conversation With… … Jennifer Schulz Moore, LLB,
MA, PhD
April 1, 2019
In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
Editor's note: Dr. Schulz Moore is the Director of Learning and Teaching at…
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psnet.ahrq.gov/node/846169/psn-pdf
March 15, 2023 - Distraction of the Anesthesiologist and Lack of
Resuscitation Drugs Resulting in Delayed Treatment of
Laryngospasm.
March 15, 2023
Bohringer C. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed
Treatment of Laryngospasm. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/…
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psnet.ahrq.gov/node/49611/psn-pdf
October 01, 2010 - The Deadly Duo
October 1, 2010
Maldonado JR. The Deadly Duo. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/deadly-duo
The Case
A 29-year-old man with a history of depression and possible psychosis was found unconscious and
unresponsive at home and was brought to the emergency department. He was tachycardi…
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psnet.ahrq.gov/node/49534/psn-pdf
May 01, 2007 - Antiseizure Medication Disorder
May 1, 2007
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
Case Objectives
Appreciate the challenges of safe use of antiepileptic medications.
Identify phenytoin toxicity.
Understand the pharmaco…
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psnet.ahrq.gov/node/49813/psn-pdf
January 01, 2018 - Dying in the Hospital With Advanced Dementia
December 1, 2017
Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
Case Objectives
Recognize the importance of eliciting patient preferences and go…
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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - SPOTLIGHT CASE
Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy
Citation Text:
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…
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psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
February 01, 2004 - SPOTLIGHT CASE
Delay in Treatment: Failure to Contact Patient Leads to Significant Complications
Citation Text:
Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - trainees should be integrated into existing hospital safety and quality processes, which can be a win–win scenario
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - resulting from discrepancies between the data used to train AI systems and the real-world clinical scenario
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psnet.ahrq.gov/node/60220/psn-pdf
April 29, 2020 - Given a scripted simulated scenario of anesthetists making clearly incorrect medical decisions,
respiratory
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - the most common diagnosis, the most dangerous diagnosis (also known as ROWS, or “Rule Out Worst Case Scenario