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281. The Forgotten Radiographic Read | PSNet
     psnet.ahrq.gov/web-mm/forgotten-radiographic-read
     June 07, 2016 - The Forgotten Radiographic Read Citation Text: Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…

282. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49809/psn-pdf
     October 01, 2017 - Hyperbilirubinemia Refractory to Phototherapy October 1, 2017 Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy The Case A 1-day-old full-term infant was noted to have elevated total serum bilirubin (…

283. Resuscitation Errors: A Shocking Problem | PSNet
     psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
     October 19, 2022 - SPOTLIGHT CASE Resuscitation Errors: A Shocking Problem Citation Text: Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: …

284. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74830/psn-pdf
     June 01, 2022 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications February 23, 2022 https://psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-co…

285. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49540/psn-pdf
     August 21, 2007 - Resuscitation Errors: A Shocking Problem August 21, 2007 Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem Case Objectives Appreciate that delays in defibrillation can have significant negative effects on sur…

286. Hyperbilirubinemia Refractory to Phototherapy | PSNet
     psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
     March 01, 2006 - Hyperbilirubinemia Refractory to Phototherapy Citation Text: Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar …

287. Rapid Response Systems | PSNet
     psnet.ahrq.gov/primer/rapid-response-systems
     July 18, 2024 - Rapid Response Systems Citation Text: Rapid Response Systems. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

288. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33589/psn-pdf
     September 15, 2024 - High Reliability September 15, 2024 High Reliability. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/high-reliability PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in …

289. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49858/psn-pdf
     April 01, 2019 - What Happened on Telemetry? April 1, 2019 Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/what-happened-telemetry Case Objectives Describe current hospital practices for continuous telemetry monitoring. Appreciate key recommendations from the Update to Practice…

290. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836885/psn-pdf
     May 16, 2022 - Management of Cardiac Arrest in Unconventional Locations. May 16, 2022 Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations The Case Case #1: An 80-year-old man with history of Parkins…

291. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33594/psn-pdf
     November 18, 2021 - Debriefing for Clinical Learning November 18, 2021 Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/debriefing-clinical-learning Updated in September 2021. Originally published in December 2011 by researchers at the University of California, S…

292. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy | PSNet
     psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
     March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy Citation Text: Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…

293. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33765/psn-pdf
     April 01, 2014 - In Conversation With… Leah Binder, MA, MGA April 1, 2014 In Conversation With… Leah Binder, MA, MGA. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga Editor's note: Leah Binder is President and CEO of The Leapfrog Group, a national nonprofit representing employers and oth…

294. Debriefing for Clinical Learning | PSNet
     psnet.ahrq.gov/primer/debriefing-clinical-learning
     September 15, 2024 - Debriefing for Clinical Learning Citation Text: Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote…

295. Management of Cardiac Arrest in Unconventional Locations. | PSNet
     psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
     June 14, 2023 - Management of Cardiac Arrest in Unconventional Locations. Citation Text: Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …

296. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851099/psn-pdf
     June 28, 2023 - Misconnection Leading to Arterial Thrombosis June 28, 2023 Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis The Case A 55-year-old man with chronic obstructive pulmonary disease (COPD) was brought by am…

297. Human Factors Engineering | PSNet
     psnet.ahrq.gov/primer/human-factors-engineering
     December 15, 2024 - Human Factors Engineering Citation Text: Human Factors Engineering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

298. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33862/psn-pdf
     July 01, 2018 - In Conversation With… Shantanu Nundy, MD July 1, 2018 In Conversation With… Shantanu Nundy, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md Editor's note: Dr. Nundy is the Director of the nonprofit organization called the Human Diagnosis Project, a unique effort to cro…

299. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73106/psn-pdf
     April 01, 2021 - Strategies and Approaches for Tracking Improvements in Patient Safety April 1, 2021 Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety Background An essential aspect …

300. In Conversation With… Leah Binder, MA, MGA | PSNet
     psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga
     February 26, 2025 - In Conversation With… Leah Binder, MA, MGA April 1, 2014  Citation Text: In Conversation With… Leah Binder, MA, MGA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Fo…