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  1. Radiology Missed an Intracranial Bleed in a Lethargic Infant. | PSNet

    psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
    August 21, 2016 - Radiology Missed an Intracranial Bleed in a Lethargic Infant. Citation Text: Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation For…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72689/psn-pdf
    January 29, 2021 - But See the Patient First January 29, 2021 Sinigayan VR. But See the Patient First. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/see-patient-first The Case   A 55-year-old man with acute myeloid leukemia presented to the emergency department (ED) with a chief complaint of fever. Five days previously, he …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33803/psn-pdf
    January 01, 2015 - In Conversation With… Richard Kronick, PhD February 1, 2014 In Conversation With… Richard Kronick, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-richard-kronick-phd Editor's note: Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since August 2013 …

  4. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. | PSNet

    psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
    October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. Citation Text: Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

  5. Verbal Orders and Medication Overrides: A Dangerous Combination | PSNet

    psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
    September 27, 2023 - Verbal Orders and Medication Overrides: A Dangerous Combination Citation Text: Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…

  6. Delayed Sepsis Management Due to Ambiguous Allergy | PSNet

    psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
    January 13, 2021 - Delayed Sepsis Management Due to Ambiguous Allergy Citation Text: Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Schol…

  7. Triaging Interhospital Transfers | PSNet

    psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
    April 12, 2023 - SPOTLIGHT CASE Triaging Interhospital Transfers Citation Text: Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX En…

  8. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy | PSNet

    psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
    March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy Citation Text: Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…

  9. Project BOOST Increases Patient Understanding of Treatment and Follow-up Care | PSNet

    psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
    February 26, 2025 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 26, 2021 Innovation Contact …

  10. Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors | PSNet

    psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
    May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 3, 2021 Innovation…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49571/psn-pdf
    October 01, 2008 - Coming Up Short October 1, 2008 Hochberg Z'ev. Coming Up Short. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/coming-short The Case A 12-year-old Hispanic female was seen for a well-child check. The child was delivered 2 months prematurely (likely due to domestic violence) in Puerto Rico. She had an intra…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33642/psn-pdf
    November 01, 2006 - In Conversation With...Donald A. Norman, PhD November 1, 2006 In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you become interested…

  13. In Conversation with...David Marx, JD | PSNet

    psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
    October 01, 2007 - This will take time, so start by removing the policies that are barriers to just culture and work incrementally

  14. In Conversation with…William B. Weeks, MD, MBA | PSNet

    psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
    May 01, 2009 - improvement efforts and to ensure that people are getting evidence-based and effective care before they start

  15. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
    January 01, 2021 - an uncommon cause of bacterial meningitis, and the most common cause of SEA – Failure to admit and start

  16. Dropping to New Lows | PSNet

    psnet.ahrq.gov/web-mm/dropping-new-lows
    December 18, 2024 - SPOTLIGHT CASE Dropping to New Lows Citation Text: Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865884/psn-pdf
    May 29, 2024 - Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. May 29, 2024 Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49831/psn-pdf
    June 01, 2018 - Chest Pain in a Rural Hospital June 1, 2018 MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital Case Objectives Recognize that a significant proportion of the Unites States population receives care in rural safety net emergency dep…

  19. The Forgotten Turn | PSNet

    psnet.ahrq.gov/web-mm/forgotten-turn
    August 01, 2018 - SPOTLIGHT CASE The Forgotten Turn Citation Text: Barbour S. The Forgotten Turn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50698/psn-pdf
    November 27, 2019 - Missed Opportunities for Suicide Risk Assessment November 27, 2019 Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…
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