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psnet.ahrq.gov/node/49682/psn-pdf
April 01, 2013 - communication failure—the pathologist's diagnostic uncertainty was not adequately conveyed to the
treating … team, and the treating team's uncertainty was not propagated forward during treatment and follow-
up
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psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - Coronavirus Disease 2019 (COVID-19) and Diagnostic
Error
January 11, 2022
Desai AN, Romano PS. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet].
2022.
https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
Originally published July 30, 2020. Updated January …
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - SPOTLIGHT CASE
The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.
Citation Text:
Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.. PSNet [internet]. Rockv…
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - A Stroke of Error
December 1, 2014
Barrett KM. A Stroke of Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/stroke-error
Case Objectives
State the key clinical factors to assess in a patient with suspected stroke.
Appreciate the relationship between elevated blood pressure and stroke in the acute sett…
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psnet.ahrq.gov/node/35053/psn-pdf
November 18, 2015 - Measured response to identified suicide risk and
violence: what you need to know about psychiatric
patient safety.
November 18, 2015
Yeager KR, Saveanu R, Roberts AR, et al. Brief Treat Crisis Intervent. 2005;5(2):121-141
https://psnet.ahrq.gov/issue/measured-response-identified-suicide-risk-and-violence-what-you-…
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psnet.ahrq.gov/perspective/relationships-between-physician-professional-satisfaction-and-patient-safety
September 29, 2017 - April 12, 2019
Detecting and treating suicide ideation in all settings.
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psnet.ahrq.gov/node/33848/psn-pdf
December 01, 2017 - .…
I'm now going to turn to the errors we made in treating this man.
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psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - Implement a quality improvement program to monitor outcomes and identify opportunities for improvement in treating
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psnet.ahrq.gov/node/41953/psn-pdf
June 19, 2013 - Potentially inappropriate medications in a large cohort of
patients in geriatric units: association with clinical and
functional characteristics.
June 19, 2013
Fromm MF, Maas R, Tümena T, et al. Potentially inappropriate medications in a large cohort of patients in
geriatric units: association with clinical and fu…
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psnet.ahrq.gov/node/34915/psn-pdf
February 27, 2009 - Emergency department visits for outpatient adverse drug
events: demonstration for a national surveillance system.
February 27, 2009
Budnitz DS, Pollock DA, Mendelsohn AB, et al. Emergency department visits for outpatient adverse drug
events: demonstration for a national surveillance system. Ann Emerg Med. 2005;45(2…
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psnet.ahrq.gov/node/37464/psn-pdf
January 16, 2008 - Variation in medication information for elderly patients
during initial interventions by emergency department
physicians.
January 16, 2008
Cohen V, Jellinek SP, Likourezos A, et al. Variation in medication information for elderly patients during
initial interventions by emergency department physicians. Am J Health…
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psnet.ahrq.gov/node/39051/psn-pdf
November 04, 2009 - On the prospects for a blame-free medical culture.
November 4, 2009
Collins ME, Block SD, Arnold RM, et al. On the prospects for a blame-free medical culture. Soc Sci Med.
2009;69(9):1287-90. doi:10.1016/j.socscimed.2009.08.033.
https://psnet.ahrq.gov/issue/prospects-blame-free-medical-culture
This study found tha…
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psnet.ahrq.gov/node/34935/psn-pdf
June 23, 2009 - Improving patient care. The cognitive psychology of
missed diagnoses.
June 23, 2009
Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med.
2005;142(2):115-120.
https://psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
This case study de…
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psnet.ahrq.gov/web-mm/nonsustained-ventricular-tachycardia-after-acute-coronary-syndromes-recognizing-high-risk
September 20, 2011 - Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients
Citation Text:
Piccini JP, Newby KL, Califf R. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - Complaints as Safety Surveillance
September 1, 2016
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance
The Case
A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain
came on sudden…
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psnet.ahrq.gov/node/49472/psn-pdf
March 01, 2005 - Preventable Rash
March 1, 2005
McLean C. Preventable Rash. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/preventable-rash
The Case
A 35-year-old man with HIV was being followed in an outpatient internal medicine clinic. At a routine visit,
screening laboratories were checked. The clinic never contacted th…
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psnet.ahrq.gov/perspective/conversation-francoise-marvel-md
August 05, 2022 - In Conversation With... Francoise Marvel, MD
August 5, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Francoise Marvel, MD. PSNet [internet]. 2022.In Conversation With... Francoise Marvel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - The Dose Makes the Poison: Medication Error During
Procedural Sedation in the Pediatric Emergency
Department.
April 26, 2023
Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the
Pediatric Emergency Department. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/do…
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psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-intermittent-episodes-dizziness-and-headache
February 08, 2023 - SPOTLIGHT CASE
Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache
Citation Text:
Edlow J. Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
May 16, 2022 - In Conversation With... Remle P. Crowe, PhD
May 16, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Remle P. Crowe, PhD . PSNet [internet]. 2022.In Conversation With... Remle P. Crowe, PhD . PSNet [internet]. Rockville (MD): Agency for Healthcare …