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  1. EMR Entry Error: Not So Benign | PSNet

    psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
    July 01, 2012 - EMR Entry Error: Not So Benign Citation Text: Koppel R. EMR Entry Error: Not So Benign. 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 X3 XML EndNote 7 XML Endno…

  2. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. | PSNet

    psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
    November 16, 2022 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. Citation Text: Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.. PSNet [inter…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73103/psn-pdf
    March 31, 2021 - Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination March 31, 2021 Valdes W, Utter GH. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-…

  4. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures | PSNet

    psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
    November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures Citation Text: Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33785/psn-pdf
    May 01, 2015 - In Conversation With… John D. Birkmeyer, MD May 1, 2015 In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md Editor's note: John D. Birkmeyer, MD, is an internationally recognized health services researcher with expertise in perfo…

  6. Errors in Sepsis Management | PSNet

    psnet.ahrq.gov/web-mm/errors-sepsis-management
    November 03, 2015 - SPOTLIGHT CASE Errors in Sepsis Management Citation Text: Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X…

  7. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
    January 01, 2020 - Spotlight Spotlight Some Patients Can’t Wait: Improving Timeliness of Emergency Department Care Source and Credits • This presentation is based on the 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm • Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD ○ Editor…

  8. In Conversation With… Andrew Bindman, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
    June 15, 2024 - In Conversation With… Andrew Bindman, MD November 1, 2016  Citation Text: In Conversation With… Andrew Bindman, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation For…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49858/psn-pdf
    April 01, 2019 - What Happened on Telemetry? April 1, 2019 Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/what-happened-telemetry Case Objectives Describe current hospital practices for continuous telemetry monitoring. Appreciate key recommendations from the Update to Practice…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865540/psn-pdf
    April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration April 11, 2024 Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration The Case An 82-year-old woman presented to the Emergency Department (ED) for …

  11. Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart | PSNet

    psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
    October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 12, 2020 …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49771/psn-pdf
    July 01, 2016 - Unintended Consequences of CPOE October 1, 2016 Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe Case Objectives Explain how technology, including computerized provider order entry, can transform, rather than eliminate, hazards. Recogni…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846915/psn-pdf
    March 29, 2023 - Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities. March 29, 2023 Bourgeois JA, Xiong G. Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/challenging-case-multiple…

  14. Technical Expert Panel | PSNet

    psnet.ahrq.gov/Information/Panel
    January 01, 2012 - Browse Author Resources Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …

  15. Annual Perspective: Psychological Safety of Healthcare Staff | PSNet

    psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
    November 16, 2022 - Annual Perspective Annual Perspective: Psychological Safety of Healthcare Staff March 31, 2022  View more articles from the same authors. Citation Text: Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. P…

  16. In Conversation With… Rebecca Lawton, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
    March 24, 2025 - In Conversation With… Rebecca Lawton, PhD September 1, 2018  Citation Text: In Conversation With… Rebecca Lawton, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49786/psn-pdf
    March 01, 2017 - Consequences of Medical Overuse March 1, 2017 Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/consequences-medical-overuse Case Objectives Define overuse and overdiagnosis. State how much of all care is estimated to be overuse. Describe why the likelihood…

  18. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. | PSNet

    psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
    August 25, 2021 - SPOTLIGHT CASE Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. Citation Text: Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …

  19. 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…

  20. Transfusion Overload | PSNet

    psnet.ahrq.gov/web-mm/transfusion-overload
    September 23, 2020 - SPOTLIGHT CASE Transfusion Overload Citation Text: Patel MS, Carson JL. Transfusion Overload. 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 En…
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