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1441. Total Parenteral Nutrition, Multifarious Errors | PSNet
      psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
      January 23, 2017 - SPOTLIGHT CASE Total Parenteral Nutrition, Multifarious Errors Citation Text: Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: …

1442. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49559/psn-pdf
      April 01, 2008 - The Forgotten Drip April 1, 2008 Josephson AS. The Forgotten Drip. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/forgotten-drip The Case A 45-year-old man was brought to the emergency department by his friends because of a 1-day history of a severe headache and "bizarre behavior." A computed tomography (C…

1443. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49767/psn-pdf
      August 21, 2016 - Falling Between the Cracks in the Software August 21, 2016 Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/falling-between-cracks-software The Case A 61-year-old man with a history of osteoarthritis was scheduled for a total knee replacement. Prio…

1444. Healthcare-associated Infections | PSNet
      psnet.ahrq.gov/primer/health-care-associated-infections
      December 15, 2024 - Healthcare-associated Infections Citation Text: Healthcare - Associated Infections. 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 t…

1445. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
      June 01, 2014 - PowerPoint Presentation Spotlight Wandering Off the Floors: Safety and Security Risks of Patient Wandering 1 This presentation is based on the June 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Thomas A. Smith, CHPA, CPP, President, Healthc…

1446. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50844/psn-pdf
      January 29, 2020 - Improving Patient Safety and Team Communication through Daily Huddles January 29, 2020 Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. 2020. https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles Background Communicat…

1447. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49473/psn-pdf
      March 01, 2005 - On O.R. Off? March 1, 2005 Leonard M. On O.R. Off? PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/or The Case An elderly man was admitted to the vascular surgery service with rest pain in his leg. Angiography demonstrated peripheral artery disease with anatomy suitable for revascularization. A consulting …

1448. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49565/psn-pdf
      July 01, 2008 - Wrong Route for Nutrients July 1, 2008 Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/wrong-route-nutrients The Case An 82-year-old man living in a skilled nursing facility (SNF) had not been eating or drinking well for about 6 months. He had lost weight and d…

1449. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49617/psn-pdf
      January 01, 2011 - Failure to Reevaluate December 1, 2010 Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/failure-reevaluate The Case A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community hospital developed methicillin-resistant staphylococc…

1450. Charcoal Lavage of the Lungs | PSNet
      psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
      January 01, 2016 - Charcoal Lavage of the Lungs Citation Text: Wigton RS. Charcoal Lavage of the Lungs. 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 …

1451. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60169/psn-pdf
      March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room. March 25, 2020 Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…

1452. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50393/psn-pdf
      September 01, 2019 - Patient Safety and the Evolution of WebM&M and PSNet September 1, 2019 Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet Perspective Progress in any field requires scholarship and dissem…

1453. Confusion With Acetaminophen | PSNet
      psnet.ahrq.gov/web-mm/confusion-acetaminophen
      December 01, 2009 - Confusion With Acetaminophen Citation Text: Heubi JE. Confusion With Acetaminophen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

1454. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49505/psn-pdf
      March 01, 2006 - Collegiality vs. Competence March 1, 2006 Sagin T. Collegiality vs. Competence. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/collegiality-vs-competence The Case A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective repair of a 10-cm abdominal aortic aneurys…

1455. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49842/psn-pdf
      September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment September 1, 2018 Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment The Case As part of…

1456. Topics | PSNet
      psnet.ahrq.gov/topics-0
      March 03, 2025 - Topics Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts. Featured Topics in Patient Safety Updated Date: March 3, 2025 …

1457. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49577/psn-pdf
      January 01, 2009 - Are Two Insulin Pumps Better Than One? January 1, 2009 Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one The Case A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass graft surge…

1458. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853080/psn-pdf
      August 30, 2023 - Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges August 30, 2023 Sanford K, Schuelke S, Lee M, et al. Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workf…

1459. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49719/psn-pdf
      September 01, 2014 - No BP During NIBP September 1, 2014 Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/no-bp-during-nibp The Case An otherwise healthy 49-year-old man with atrial fibrillation was scheduled for ablation in the catheterization laboratory under general endotracheal anes…

1460. Curated Article Libraries | PSNet
      psnet.ahrq.gov/curated-article-libraries
      March 18, 2025 - Curated Libraries Curated Libraries are groupings of PSNet content, curated by AHRQ and by other experts in the patient safety field. Watch the video to learn more about how this new feature works and how it can be of benefit to you. Latest PSNet…