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  1. Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax | PSNet

    psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
    December 14, 2022 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax Citation Text: Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49829/psn-pdf
    May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865778/psn-pdf
    May 29, 2024 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement May 29, 2024 Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-complications-unint…

  4. Reaction to Dye | PSNet

    psnet.ahrq.gov/web-mm/reaction-dye
    March 01, 2007 - Reaction to Dye Citation Text: Cohan R. Reaction to Dye. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  5. Undetected Foreign Object | PSNet

    psnet.ahrq.gov/web-mm/undetected-foreign-object
    April 24, 2018 - Undetected Foreign Object Citation Text: Cima RR. Undetected Foreign Object. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…

  6. Complications of Vascular Access Procedures in Patients with Kidney Disease | PSNet

    psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
    November 15, 2023 - Complications of Vascular Access Procedures in Patients with Kidney Disease Citation Text: Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

  7. The Safety Challenges of Supervision and Night Coverage in Academic Residency | PSNet

    psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
    February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency Citation Text: Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…

  8. Missed Patient Assignment: Is Anyone There? | PSNet

    psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
    September 01, 2017 - Missed Patient Assignment: Is Anyone There? Citation Text: Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google …

  9. Diagnostic Error | PSNet

    psnet.ahrq.gov/curated-library/diagnostic-error
    September 14, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Error  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Karen Cosby, AHRQ Date Created: May 8, …

  10. Burnout | PSNet

    psnet.ahrq.gov/primer/burnout
    November 20, 2024 - Burnout Citation Text: Yellowlees P, Rea M. Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Do…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855057/psn-pdf
    October 31, 2023 - Addressing Workplace Violence and Creating a Safer Workplace October 31, 2023 Jones CB, Sousane Z, Mossburg S. Addressing Workplace Violence and Creating a Safer Workplace. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace While violence in the w…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33877/psn-pdf
    April 01, 2019 - In Conversation With… Timothy B. McDonald, MD, JD April 1, 2019 In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd Editor's note: Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar…

  13. To Transfer or Not to Transfer | PSNet

    psnet.ahrq.gov/web-mm/transfer-or-not-transfer
    November 23, 2016 - SPOTLIGHT CASE To Transfer or Not to Transfer Citation Text: Pines JM. To Transfer or Not to Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote …

  14. Impact of System Failures on Healthcare Workers | PSNet

    psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
    August 30, 2023 - Annual Perspective Impact of System Failures on Healthcare Workers George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD | March 21, 2023  View more articles from the same authors. Citation Text: Zangaro G, Van CM, Mossburg S. Imp…

  15. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement | PSNet

    psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
    February 23, 2022 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement Citation Text: Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…

  16. Root Cause Analysis Gone Wrong | PSNet

    psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
    August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…

  17. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet

    psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
    November 27, 2019 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities Citation Text: Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…

  18. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! | PSNet

    psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
    February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! Citation Text: Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…

  19. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
    January 01, 2024 - Spotlight Spotlight A Fatal Twist in Pseudohyperkalemia 1 Source and Credits This presentation is based on the August 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Le…

  20. Code Status Confusion | PSNet

    psnet.ahrq.gov/web-mm/code-status-confusion
    September 01, 2006 - SPOTLIGHT CASE Code Status Confusion Citation Text: Lo B, Tulsky JA. Code Status Confusion. 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 EndN…
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