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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - cause VF. 17,18 In an experimental study, a current as small as 550 micro-amperes could induce VF. 19 Approaches
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psnet.ahrq.gov/perspective/conversation-maureen-bisognano
February 26, 2025 - But to me it's a leadership system to define the two approaches and to get the call right.
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 4: Technology and Medication
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - pandemic placed demands on everyone in the health system, leading to improvised actions and testing approaches
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - appearance of free fluid was likely “the earliest indicator of an acute abdomen needing surgery.” 13 Approaches
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psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - has focused on patient safety and reducing errors using information systems and other system-based approaches
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psnet.ahrq.gov/node/60329/psn-pdf
May 14, 2020 - In Conversation With... Joel Willis, DO, PA, MA, MPhiL
and Neal Sikka, MD
May 14, 2020
In Conversation With.. Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
Editor’s note: Joel Willis, DO, PA, M…
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psnet.ahrq.gov/web-mm/privacy-or-safety
December 01, 2011 - SPOTLIGHT CASE
Privacy or Safety?
Citation Text:
Halamka JD, McGraw D. Privacy or Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNo…
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psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - Hidden Heparins: HIT Happens
December 1, 2006
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
Case Objectives
Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication,
thrombosis.
Discuss the managem…
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psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
March 01, 2005 - SPOTLIGHT CASE
CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure
Citation Text:
Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…
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psnet.ahrq.gov/node/33750/psn-pdf
May 01, 2013 - In Conversation With… Ashish K. Jha, MD, MPH
May 1, 2013
In Conversation With… Ashish K. Jha, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
Editor's note: Ashish K. Jha, MD, MPH, is professor of health policy and management at the Harvard
School of Public Hea…
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
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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.
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psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
January 29, 2021 - An Incomplete Anesthesia History Leads to Adverse Outcomes
Citation Text:
Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Format:
…
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near-
Miss Wrong Transfusion Event
January 29, 2020
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
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psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
February 01, 2004 - SPOTLIGHT CASE
Delay in Treatment: Failure to Contact Patient Leads to Significant Complications
Citation Text:
Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM
April 1, 2018
In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and
Directo…
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psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
June 01, 2017 - In Conversation With… Paul Aylin, MBChB
June 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Paul Aylin, MBChB. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy …
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psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - Hidden Danger! Insidious Postpartum Bleeding After
Emergency Cesarean Delivery.
November 30, 2021
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean
Delivery. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emerg…
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psnet.ahrq.gov/node/33748/psn-pdf
April 01, 2013 - In Conversation With… Christopher P. Landrigan, MD,
MPH
April 1, 2013
In Conversation With… Christopher P. Landrigan, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
Editor's note: Christopher P. Landrigan, MD, is Associate Professor of Medicine and …