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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
    January 01, 2022 - Spotlight Spotlight Intraosseous Line Extravasation in a Pediatric Trauma Patient Source and Credits • This presentation is based on the April 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: David Barnes, MD and Joseph Yoon, MD o…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72516/psn-pdf
    November 25, 2020 - Premature Closure: Was It Just Syncope? November 25, 2020 Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
  3. psnet.ahrq.gov/perspective/conversation-rebecca-smith-bindman-md
    October 01, 2013 - When we looked at patients grouped by clinical condition being assessed—such as PE or stroke—the doses
  4. psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - • On further review, it became apparent that a third surgeon had assessed the patient near the end
  5. psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
    June 15, 2024 - Inpatient Transitions of Care: Challenges and Safety Practices Citation Text: Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation …
  6. psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
    January 29, 2020 - Delayed Diagnosis of Kidney Transplant Complications Citation Text: Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Goo…
  7. psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
    February 01, 2014 - Wrong-Time Error With High-Alert Medication Citation Text: Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX…
  8. psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
    August 31, 2020 - Annual Perspective Approach to Improving Patient Safety: Communication March 10, 2021  View more articles from the same authors. Citation Text: Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. Ro…
  9. psnet.ahrq.gov/web-mm/do-me-favor
    September 12, 2016 - Do Me a Favor Citation Text: Williamson A. Do Me a Favor. 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 …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838972/psn-pdf
    October 27, 2022 - The Unhappy Patient Leaves Against Medical Advice. October 27, 2022 Nichols A. The Unhappy Patient Leaves Against Medical Advice. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice The Case A 61-year-old woman was placed on bedrest following major surgery. Her posto…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49696/psn-pdf
    December 01, 2013 - New Oral Anticoagulants December 1, 2013 Fang MC. New Oral Anticoagulants. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/new-oral-anticoagulants Case Objectives Review properties of newer target-specific oral anticoagulants (TSOACs) such as dabigatran, rivaroxaban, and apixaban. State key perioperative c…
  12. psnet.ahrq.gov/perspective/context-intervention
    August 05, 2020 - The Context Is the Intervention Dr. John Øvretveit | October 1, 2011  View more articles from the same authors. Citation Text: Øvretveit J. The Context Is the Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
  13. psnet.ahrq.gov/web-mm/routine-goes-awry
    September 23, 2020 - Routine Goes Awry Citation Text: Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852699/psn-pdf
    August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety August 30, 2023 Van CM, Mossburg S, McGaffigan P. Beyond the Pandemic: Creating Total Systems Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety The COVID-19 pandemic necessitated a shift in operations …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60330/psn-pdf
    May 05, 2020 - Telehealth and Patient Safety During the COVID-19 Response May 14, 2020 Sikka N, Willis JS, Fitall E, et al. Telehealth and Patient Safety During the COVID-19 Response. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response Introduction   Telehealth typ…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49504/psn-pdf
    March 01, 2006 - Liposuction Gone Awry March 1, 2006 Yates JA. Liposuction Gone Awry. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/liposuction-gone-awry The Case A 54-year-old man with HIV was referred to a plastic surgeon for cosmetic surgery. In the plastic surgeon’s office, he underwent neck and facial liposuction wit…
  17. psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
    April 24, 2018 - Written Signout: It Only Works If You Use The Right One Citation Text: Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49620/psn-pdf
    February 01, 2011 - Silent Pain in the Neck February 1, 2011 Bittner EA. Silent Pain in the Neck. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/silent-pain-neck The Case A 60-year-old man with no significant past medical history underwent an elective anterior cervical discectomy for persistent right arm weakness due to cervi…
  19. psnet.ahrq.gov/web-mm/allergy-holter
    May 01, 2008 - Allergy to Holter Citation Text: Williams M. Allergy to Holter. 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 …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49458/psn-pdf
    September 01, 2004 - Poor Prognosis September 1, 2004 Lamont EB. Poor Prognosis. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/poor-prognosis Case Objectives Understand the current limitations of physicians' ability to provide prognoses. List the variables that can be used to guide treatment decisions and prognostication in e…

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