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1481. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841566/psn-pdf
      December 14, 2022 - In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety December 14, 2022 In Conversation With.. Dr. Michelle Schreiber on Measuring Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety Editor’s Note: Michelle Schr…

1482. Diagnostic Errors Case Studies | PSNet
      psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
      November 03, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Errors Case Studies  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Maria Mirica, PRIDE Group …

1483. Collegiality vs. Competence | PSNet
      psnet.ahrq.gov/web-mm/collegiality-vs-competence
      August 28, 2024 - Collegiality vs. Competence Citation Text: Sagin T. Collegiality vs. Competence. 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 tagg…

1484. Think Like a Surgeon | PSNet
      psnet.ahrq.gov/web-mm/think-surgeon
      December 04, 2024 - Think Like a Surgeon Citation Text: Cooper Z. Think Like a Surgeon. 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…

1485. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
      April 01, 2013 - Spotlight Case July 2008 Spotlight Case Total Parenteral Nutrition, Multifarious Errors * * Source and Credits This presentation is based on the April 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Joseph I. Boullata, PharmD, RPh, BCNSP…

1486. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49569/psn-pdf
      September 01, 2008 - Where's the Feeding Tube? September 1, 2008 Metheny NA, Meert KL. Where's the Feeding Tube? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/wheres-feeding-tube The Case A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic brain injury. Because of the injuries, he was unabl…

1487. Too Much, Too Fast | PSNet
      psnet.ahrq.gov/web-mm/too-much-too-fast
      June 14, 2019 - Too Much, Too Fast Citation Text: Tuot D. Too Much, Too Fast. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

1488. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49715/psn-pdf
      August 21, 2014 - Liver Biopsy: Proceed With Caution August 21, 2014 Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution The Case A 42-year-old woman with a history of multiple malignancies, including osteosarcoma and recurrent breast cancer, presented t…

1489. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49490/psn-pdf
      September 01, 2005 - The Wrong Channel September 1, 2005 Gosbee JW. The Wrong Channel . PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/wrong-channel The Case A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial dosing started at 50 mL/hour using a multi-channel medication pump…

1490. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention | PSNet
      psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
      May 01, 2011 - Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention Citation Text: Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Cop…

1491. Delayed Diagnosis of Kidney Transplant Complications | PSNet
      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…

1492. 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 …

1493. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50701/psn-pdf
      November 26, 2019 - In Conversation With... Heidi Wald, MD November 26, 2019 In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-heidi-wald-md Editor’s note: Dr. Wald, MD, MSPH, is the Chief Quality and Safety Officer at SCL Health in Denver, CO. She has previously served as …

1494. 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. …

1495. Dangerous Dapsone | PSNet
      psnet.ahrq.gov/web-mm/dangerous-dapsone
      January 10, 2011 - Dangerous Dapsone Citation Text: Bookwalter T. Dangerous Dapsone. 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…

1496. Wrong-side Bedside Paravertebral Block: Preventing the Preventable | PSNet
      psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
      August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable Citation Text: Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy C…

1497. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49731/psn-pdf
      April 01, 2015 - Fire in the Hole!—An OR Fire April 1, 2015 Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fire-hole-or-fire The Case A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinom…

1498. Are Two Insulin Pumps Better Than One? | PSNet
      psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one
      March 01, 2005 - Are Two Insulin Pumps Better Than One? Citation Text: Cook CB. Are Two Insulin Pumps Better Than One?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndN…

1499. How Does Infection Prevention Fit Into a Safety Program? | PSNet
      psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
      March 01, 2014 - How Does Infection Prevention Fit Into a Safety Program? Susan S. Huang, MD, MPH | March 1, 2014  Also Read a Conversation View more articles from the same authors. Citation Text: Huang SS. How Does Infection Prevention Fit Into a Safety Program?. PSNet [interne…

1500. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49398/psn-pdf
      May 01, 2003 - Bloody BP Cuff May 1, 2003 Madan AK. Bloody BP Cuff. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/bloody-bp-cuff The Case Patient #1, a 28-year-old male, was a trauma patient following a motor vehicle collision into a cement pillar. Patient #1 was in the trauma bay with massive injuries and profuse bleed…