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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49606/psn-pdf
    August 01, 2010 - Weighing In on Surgical Safety August 1, 2010 Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/weighing-surgical-safety Case Objectives Identify the comorbidites associated with obesity that place patients at higher risk for surgical complications. Un…

  2. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. | PSNet

    psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
    August 21, 2005 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism. Citation Text: Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49639/psn-pdf
    November 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin…

  4. 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. …

  5. 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…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60269/psn-pdf
    April 29, 2020 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? April 29, 2020 Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tiss…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49485/psn-pdf
    August 29, 2024 - Blind Spot June 1, 2005 Lee LA. Blind Spot. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/blind-spot The Case A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49550/psn-pdf
    December 01, 2007 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? December 1, 2007 Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals The Case …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73455/psn-pdf
    June 30, 2021 - Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks June 30, 2021 Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks The Case At the…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49760/psn-pdf
    May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…

  11. The Safety Challenges of Supervision and Night Coverage in Academic Residency | PSNet

    psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
    February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency Citation Text: Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…

  12. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
    January 01, 2024 - Spotlight Spotlight A Fatal Twist in Pseudohyperkalemia 1 Source and Credits This presentation is based on the August 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Le…

  13. Getting the Diagnosis Both Right and Wrong | PSNet

    psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
    May 29, 2024 - Getting the Diagnosis Both Right and Wrong Citation Text: Olson AP. Getting the Diagnosis Both Right and Wrong. 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…

  14. The Different Count Contributions to Retention (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
    January 01, 2024 - The Different Count Contributions to Retention Differential Count Contributions in Retained Surgical Sponge Cases: Examination of Administrative Penalty Cases from the California Department of Public Health (CDPH), Health and Safety Code Section 1280.1 Enforcement Reports from 2007-2014 A NoThing Left Behin…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33818/psn-pdf
    November 01, 2016 - In Conversation With… Andrew Bindman, MD November 1, 2016 In Conversation With… Andrew Bindman, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-andrew-bindman-md Editor's note: Dr. Bindman was appointed as Director of the Agency for Healthcare Research and Quality (AHRQ) in May 2016. P…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49699/psn-pdf
    February 01, 2014 - Multifactorial Medication Mishap February 1, 2014 Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap Case Objectives Understand the system-based causes of medication errors. Describe a model for a systems approach to error analysis. Id…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33643/psn-pdf
    December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA December 1, 2006 In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma Editor's Note: J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and Critic…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33746/psn-pdf
    March 01, 2013 - In Conversation With… David M. Gaba, MD March 1, 2013 In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of Medicine. An international leade…

  19. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-309
    September 29, 2021 - September 15, 2021 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, repo…

  20. Failed Interpretation of Screening Tool: Delayed Treatment | PSNet

    psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
    August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment Citation Text: Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citatio…
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