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psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
April 01, 2008 - SPOTLIGHT CASE
A "Reflexive" Diagnosis in Primary Care
Citation Text:
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/death-pca
January 06, 2017 - Death by PCA
Citation Text:
Hicks RW. Death by PCA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Dow…
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psnet.ahrq.gov/node/60721/psn-pdf
July 21, 2020 - Special Edition Perspective: Technology Responses to
COVID-19
July 21, 2020
Marcin JP, Cohen NM, Lowery C, et al. Special Edition Perspective: Technology Responses to COVID-19.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19
Editor’s note: This …
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psnet.ahrq.gov/periodic-issue/periodic-issue-439
May 29, 2024 - May 8, 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, an…
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - Decision-making in the management of colonoscopic perforation: a multicentre retrospective study.
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - Challenges of Diabetes Management and Medication Reconciliation
Citation Text:
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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…
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - Delayed Breast Cancer Diagnosis: A False Sense of Security.
Citation Text:
Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security.. 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/web-mm/mismanagement-delirium
February 13, 2014 - organizations and providers ensure patients and families are encouraged to participate in care planning and decision-making
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
April 27, 2022 - bleeding is brisk, laboratory results are typically not available fast enough to help guide clinical decision … making.
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psnet.ahrq.gov/node/60543/psn-pdf
May 27, 2020 - with the service performing the
procedure provides specialty guidance and can assist with clinical decision-making
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - SPOTLIGHT CASE
Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations
Citation Text:
Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. PSNet [internet]. Rockville (MD): Agency for He…
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psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - SPOTLIGHT CASE
Right? Left? Neither!
Citation Text:
Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/worst-headache
July 01, 2016 - The Worst Headache
Citation Text:
Edlow JA. The Worst Headache. 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/primer/medication-administration-errors
December 15, 2024 - Medication Administration Errors
Citation Text:
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/primer/long-term-care-and-patient-safety
February 24, 2022 - Long-term Care and Patient Safety
Citation Text:
Bakerjian D. Long-term Care and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/periodic-issue/periodic-issue-400
July 31, 2023 - July 19, 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/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - Many of these errors are best categorized as cognitive and relate to a clinician’s decision-making,
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - SPOTLIGHT CASE
Getting to the Root of the Matter
Citation Text:
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - SPOTLIGHT CASE
Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture
Citation Text:
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. PSNet [internet]. Rockville (MD): Agency fo…