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7421. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
      June 01, 2013 - Spotlight Case July 2008 Spotlight Case Emergency Error 1 2 Source and Credits This presentation is based on the June 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London Editor, AHRQ WebM&M: Robe…

7422. Hold the tPA | PSNet
      psnet.ahrq.gov/web-mm/hold-tpa
      July 29, 2020 - Hold the tPA Citation Text: Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

7423. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865418/psn-pdf
      March 27, 2024 - Cybersecurity and How to Maintain Patient Safety March 27, 2024 Pelletreau B, Riggi J, Gale B, et al. Cybersecurity and How to Maintain Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety Introduction The integration of information technology (I…

7424. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49853/psn-pdf
      February 01, 2019 - Adverse Event During Intrahospital Transport February 1, 2019 Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport The Case A 4-year-old boy underwent surgery under general anesthesia for correction o…

7425. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863641/psn-pdf
      February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training February 28, 2024 Haugstetter M, Hines S, Sousane Z, et al. Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork…

7426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49709/psn-pdf
      May 01, 2014 - Raise the Bar May 1, 2014 Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/raise-bar The Case A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The patient was seen and evaluated by an anesthesiologist who was new to the cente…

7427. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49580/psn-pdf
      March 21, 2009 - Medication Reconciliation Victory After an Avoidable Error March 21, 2009 Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error The Case A 91-year-old woman, previously active and indepen…

7428. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49614/psn-pdf
      November 01, 2010 - Reconciling Records November 1, 2010 Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/reconciling-records The Cases   Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local teaching hospital. When discharged, h…

7429. Chemotherapy Administration Safety Standards | PSNet
      psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
      March 30, 2016 - Chemotherapy Administration Safety Standards Citation Text: Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX En…

7430. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49430/psn-pdf
      January 01, 2004 - Triage Time Bomb January 1, 2004 Washington DL. Triage Time Bomb. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/triage-time-bomb The Case A parent presented with a child to the emergency department (ED) triage area (located around the corner and down the hall from the actual ED). The child was febrile, an…

7431. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50843/psn-pdf
      January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia January 29, 2020 Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia The Case A 54-year-old man was brought t…

7432. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49726/psn-pdf
      March 01, 2015 - Two Wrongs Don't Make a Right (Kidney) March 1, 2015 DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney Case Objectives Review the current definition of wrong-site surgery. Describe the incidence of wrong-site surgery, and the…

7433. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49686/psn-pdf
      May 01, 2013 - Don't Use That Port: Insert a PICC May 1, 2013 Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc The Case A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with fever and abdominal pain. A comp…

7434. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49616/psn-pdf
      December 01, 2010 - Milliliters vs. Milligrams December 1, 2010 Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams The Case   A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His evaluation showed acu…

7435. Indwelling Urinary Catheter Insertion Facilitator Notes
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-insertion.pptx
      April 01, 2022 - Indwelling Urinary Catheter Insertion Facilitator Notes Indwelling Urinary Catheter Insertion Ensuring Aseptic Placement AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI AHRQ Pub. No. 17(22)-0019 April 2022 1 Why Is Aseptic Insertion So Important?1-3 2020 National Healthcare Safety Netw…

7436. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49394/psn-pdf
      April 01, 2003 - Premature or Overdue? April 1, 2003 Thomas J, Hannah M. Premature or Overdue? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/premature-or-overdue The Case A 32-year-old woman, gravida 3, para 1, presented for prenatal care at 24 weeks. Her past medical history was unremarkable, and results of her prenatal …

7437. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49796/psn-pdf
      June 01, 2017 - Chest Tube Complications June 1, 2017 Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/chest-tube-complications The Case A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for management of a spontaneous left pneumothorax (coll…

7438. Practice Member Survey Baseline (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/member-survey-baseline-nc.pdf
      January 01, 2014 - Practice Member Survey Baseline …

7439. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49704/psn-pdf
      March 01, 2014 - Late Anemia Following Rh Disease in a Newborn March 1, 2014 Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn The Case A full-term neonate was delivered uneventfully to an Rh-negative woman who had re…

7440. Rapid Mis-St(r)ep | PSNet
      psnet.ahrq.gov/web-mm/rapid-mis-strep
      February 01, 2004 - Rapid Mis-St(r)ep Citation Text: Kaplan EL. Rapid Mis-St(r)ep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …