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psnet.ahrq.gov/node/49668/psn-pdf
October 01, 2012 - Buprenorphine and the Medically Ill Patient
October 1, 2012
McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
The Case
A 60-year-old man with a 15-year history of oxycodone dependence presented to a substance …
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psnet.ahrq.gov/node/49856/psn-pdf
March 01, 2019 - Premature Extubation
March 1, 2019
Sagana R, Hyzy RC. Premature Extubation. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/premature-extubation
The Case
A 73-year-old woman with a history of carotid artery stenosis was admitted for an elective carotid
endarterectomy. The procedure was initially thought to …
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia
Citation Text:
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/40-k
January 12, 2011 - 40 of K
Citation Text:
Lesar TS. 40 of K. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/premature-or-overdue
December 23, 2020 - Premature or Overdue?
Citation Text:
Thomas J, Hannah M. Premature or Overdue?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
January 07, 2015 - Dropping the Ball Despite an Integrated EMR
Citation Text:
Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - Misplaced Nasogastric Tube Resulting in Aspiration
Citation Text:
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/node/49657/psn-pdf
July 01, 2012 - Not-So-Therapeutic Tap
July 1, 2012
Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
Case Objectives
Describe current issues with training clinicians to perform procedures.
Understand how simulation can be used to ensure trainees are competent in proc…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
September 27, 2023 - SPOTLIGHT CASE
Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation
Citation Text:
Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation. PSNet [internet]. Rockville (MD): Agency for Health…
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx
Spotlight
Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See…
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psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
September 01, 2012 - Preparing for Health Reform: The Federal Government and the Nursing Workforce
Peter I. Buerhaus, PhD, RN | September 1, 2012
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Buerhaus P. Preparing for Health Reform: The Federal G…
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psnet.ahrq.gov/node/836840/psn-pdf
April 22, 2021 - prescriber feedback
A shared understanding of best practices and use of standardized protocols for assessing
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psnet.ahrq.gov/issue/investigation-management-venous-thromboembolism-risk-patients-following-thrombolysis-acute
November 13, 2019 - Book/Report
Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke.
Citation Text:
Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke. Farnborough, UK; Healthcare…
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psnet.ahrq.gov/issue/ismp-long-term-care-advise-err
June 07, 2017 - Newsletter/Journal
ISMP Long-Term Care Advise-ERR.
Citation Text:
ISMP Long-Term Care Advise-ERR. Horsham, PA; Institute for Safe Medication Practices.
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psnet.ahrq.gov/issue/safety-anesthetic-and-perioperative-medication-practices
January 14, 2019 - Newspaper/Magazine Article
Safety of anesthetic and perioperative medication practices.
Citation Text:
Safety of anesthetic and perioperative medication practices. Meyer TA. Anesthesiology News. October 31, 2022.
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psnet.ahrq.gov/issue/disclosure-and-apology-whats-missing-advancing-programs-support-clinicians
December 07, 2016 - Book/Report
Disclosure and Apology: What's Missing? Advancing Programs that Support Clinicians.
Citation Text:
Disclosure and Apology: What's Missing? Advancing Programs that Support Clinicians. Carr S. Chestnut Hill, MA: Medically Induced Trauma Support Services; 2009.
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psnet.ahrq.gov/issue/diagnostic-safety-event-reporting
August 05, 2020 - Newspaper/Magazine Article
Diagnostic safety event reporting.
Citation Text:
Diagnostic safety event reporting. Carr S. ImproveDx. July 2021;8(4).
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psnet.ahrq.gov/issue/accidental-iv-infusion-heparinized-irrigation-or
September 14, 2016 - Newspaper/Magazine Article
Accidental IV infusion of heparinized irrigation in the OR.
Citation Text:
Accidental IV infusion of heparinized irrigation in the OR. ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.
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psnet.ahrq.gov/issue/studying-organisational-cultures-and-their-effects-safety
April 20, 2014 - Commentary
Studying organisational cultures and their effects on safety.
Citation Text:
Hopkins A. Studying organisational cultures and their effects on safety. Saf Sci. 2006;44(10). doi:10.1016/j.ssci.2006.05.005.
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psnet.ahrq.gov/issue/impact-professionalism-safe-surgical-care
January 23, 2017 - Commentary
The impact of professionalism on safe surgical care.
Citation Text:
Whittemore A, Surgery NES for V. The impact of professionalism on safe surgical care. J Vasc Surg. 2007;45(2):415-9.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 …