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241. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74253/psn-pdf
     January 12, 2022 - Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic January 12, 2022 Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/patient…

242. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50842/psn-pdf
     January 29, 2020 - Patient Identification Errors: A Systems Challenge January 29, 2020 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge The Cases The following four events involving five patients all involved…

243. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/860015/psn-pdf
     September 01, 2024 - Retained Surgical Items: Definition and Epidemiology. January 4, 2024 Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology. PSNet [internet]. 2024. https://psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology Background Prudent medical practice and federal and state laws r…

244. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49674/psn-pdf
     December 01, 2012 - Preventing PICC Complications: Whose Line Is It? December 1, 2012 Moureau N. Preventing PICC Complications: Whose Line Is It? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it The Case A 55-year-old woman with myasthenia gravis, hypertension, and hypothyroidism prese…

245. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment | PSNet
     psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
     June 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment Citation Text: Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …

246. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue | PSNet
     psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
     May 01, 2016 - Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue Samantha Jacques, PhD, and Eric Williams, MD, MS, MMM | May 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Jacques S, Williams E. Reducing the Safety Hazar…

247. Premature or Overdue? | PSNet
     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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

248. Lapse in Antibiotics Leads to Sepsis | PSNet
     psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
     November 21, 2021 - Lapse in Antibiotics Leads to Sepsis Citation Text: Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

249. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/840256/psn-pdf
     November 16, 2022 - What are you doing with improving maternal health and babies?

250. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50613/psn-pdf
     October 30, 2019 - Gorillas deliver their own babies, but we walk upright; we have narrower pelvises.

251. Waiting Too Long | PSNet
     psnet.ahrq.gov/web-mm/waiting-too-long
     February 01, 2013 - Waiting Too Long Citation Text: Rosen MA. Waiting Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

252. Preventing PICC Complications: Whose Line Is It? | PSNet
     psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
     October 01, 2017 - Preventing PICC Complications: Whose Line Is It? Citation Text: Moureau N. Preventing PICC Complications: Whose Line Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibT…

253. Late Anemia Following Rh Disease in a Newborn | PSNet
     psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
     June 17, 2010 - Late Anemia Following Rh Disease in a Newborn Citation Text: Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Schola…

254. Patient Identification Errors: A Systems Challenge | PSNet
     psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
     February 23, 2011 - Patient Identification Errors: A Systems Challenge Citation Text: Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Googl…

255. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49568/psn-pdf
     September 01, 2008 - Failure to Latch September 1, 2008 Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/failure-latch The Case The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to breastfeeding exclusively for 6 months. However, early br…

256. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852808/psn-pdf
     August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication Breakdown. August 30, 2023 Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown Disclosure of Relevant Financial Relationship…

257. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
     January 01, 2023 - Spotlight Spotlight Prolonged DKA in Pregnancy: A Case of Communication Breakdown Source and Credits • This presentation is based on the August 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Sarah Marshall, MD and Nina M. …

258. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49531/psn-pdf
     March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…

259. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49676/psn-pdf
     February 01, 2013 - Death by PCA February 1, 2013 Hicks RW. Death by PCA. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/death-pca The Case A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …

260. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33754/psn-pdf
     September 01, 2013 - In Conversation With… Sidney Dekker, MA, MSc, PhD September 1, 2013 In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd Editor's note: Sidney Dekker is Professor and Director of the Safety Science Innovation Lab at Grif…