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1501. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49662/psn-pdf
      August 01, 2012 - Wrong Turn through Colon: Misplaced PEG August 1, 2012 Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg The Case An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…

1502. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50612/psn-pdf
      October 30, 2019 - The Safety Challenges of Supervision and Night Coverage in Academic Residency October 30, 2019 Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency The Case…

1503. Adverse Event During Intrahospital Transport | PSNet
      psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
      June 16, 2021 - Adverse Event During Intrahospital Transport Citation Text: Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar …

1504. Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis | PSNet
      psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
      February 26, 2025 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 31, 2023 Innovation Contact …

1505. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849592/psn-pdf
      May 31, 2023 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans May 31, 2023 https://psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create- customized-prevention Summary Patient falls in hospitals are common and debilitating adverse events that persis…

1506. Bloody BP Cuff | PSNet
      psnet.ahrq.gov/web-mm/bloody-bp-cuff
      June 21, 2016 - Bloody BP Cuff Citation Text: Madan AK. Bloody BP Cuff. 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 …

1507. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50389/psn-pdf
      September 25, 2019 - Getting the Diagnosis Both Right and Wrong September 25, 2019 Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong The Case A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…

1508. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840175/psn-pdf
      November 16, 2022 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism. November 16, 2022 Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism The Case A 61-year-old woman presented to …

1509. Is the "Surgical Personality" a Threat to Patient Safety? | PSNet
      psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
      February 24, 2021 - SPOTLIGHT CASE Is the "Surgical Personality" a Threat to Patient Safety? Citation Text: Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citati…

1510. Diagnostic Failure: The Growing Deficit | PSNet
      psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
      June 01, 2005 - Diagnostic Failure: The Growing Deficit Citation Text: Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNo…

1511. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49819/psn-pdf
      February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…

1512. The Wrong Channel | PSNet
      psnet.ahrq.gov/web-mm/wrong-channel
      February 01, 2003 - The Wrong Channel Citation Text: Gosbee JW. The Wrong Channel . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

1513. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842923/psn-pdf
      February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. February 1, 2023 Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …

1514. 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 …

1515. Where's the Feeding Tube? | PSNet
      psnet.ahrq.gov/web-mm/wheres-feeding-tube
      September 01, 2003 - Where's the Feeding Tube? Citation Text: Metheny NA, Meert KL. Where's the Feeding Tube?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

1516. 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…

1517. Preventable Rash | PSNet
      psnet.ahrq.gov/web-mm/preventable-rash
      October 01, 2012 - Preventable Rash Citation Text: McLean C. Preventable Rash. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

1518. Poorly Advanced Directives | PSNet
      psnet.ahrq.gov/web-mm/poorly-advanced-directives
      August 01, 2018 - Poorly Advanced Directives Citation Text: Anderson WG. Poorly Advanced Directives. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…

1519. In Conversation With… Sharon K. Inouye, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
      December 01, 2012 - In Conversation With… Sharon K. Inouye, MD, MPH December 1, 2012  Also Read an Essay Citation Text: In Conversation With… Sharon K. Inouye, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…

1520. Lost in Sign Out and Documentation | PSNet
      psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
      January 31, 2011 - Lost in Sign Out and Documentation Citation Text: Detsky ME. Lost in Sign Out and Documentation. 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 7 …