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psnet.ahrq.gov/issue/management-patient-latex-allergy
June 21, 2017 - Commentary
Management of a patient with a latex allergy.
Citation Text:
Minami CA, Barnard C, Bilimoria KY. Management of a Patient With a Latex Allergy. JAMA. 2017;317(3):309-310. doi:10.1001/jama.2016.20034.
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psnet.ahrq.gov/issue/nursing-student-medication-errors-involving-tubing-and-catheters-descriptive-study
July 14, 2010 - Study
Nursing student medication errors involving tubing and catheters: a descriptive study.
Citation Text:
Wolf ZR, Hicks RW, Altmiller G, et al. Nursing student medication errors involving tubing and catheters: A descriptive study. Nurse Educ Today. 2009;29(6). doi:10.1016/j.nedt.200…
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psnet.ahrq.gov/issue/statewide-nicu-central-line-associated-bloodstream-infection-rates-decline-after-bundles-and
September 23, 2020 - Study
Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.
Citation Text:
Schulman J, Stricof R, Stevens TP, et al. Statewide NICU central-line-associated bloodstream infection rates decline after bundles and checklists. Pediatrics. 201…
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - Around the Block
Citation Text:
Minichiello T. Around the Block. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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psnet.ahrq.gov/issue/safety-risk-air-embolus-associated-central-venous-catheters-used-haemodialysis-treatment
April 05, 2023 - Book/Report
Safety Risk of Air Embolus Associated with Central Venous Catheters Used for Haemodialysis Treatment.
Citation Text:
Safety Risk of Air Embolus Associated with Central Venous Catheters Used for Haemodialysis Treatment. Farnborough, UK: Healthcare Safety Investigation Branch. …
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psnet.ahrq.gov/node/73335/psn-pdf
May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition
Error
May 26, 2021
Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
The Case
A 4-year-old (former 33-week premature) boy with a …
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psnet.ahrq.gov/issue/collaborative-cohort-study-intervention-reduce-ventilator-associated-pneumonia-intensive-care
September 20, 2011 - Study
Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.
Citation Text:
Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive …
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psnet.ahrq.gov/issue/improving-patient-safety-intensive-care-units-michigan
February 17, 2011 - Study
Classic
Improving patient safety in intensive care units in Michigan.
Citation Text:
Pronovost P, Berenholtz SM, Goeschel CA, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-212. doi:10.1016/j.jcrc.2007.09…
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psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-preventable-complications
January 22, 2014 - Commentary
Classic
The wisdom and justice of not paying for "preventable complications."
Citation Text:
Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.1…
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psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
April 24, 2024 - The Danger of 10% Intravenous Calcium Chloride Extravasation.
Citation Text:
The Danger of 10% Intravenous Calcium Chloride Extravasation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
December 01, 2013 - PowerPoint Presentation
Spotlight Case
New Oral Anticoagulants
1
This presentation is based on the December 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Margaret C. Fang, MD, MPH, University of California, San Francisco
Editor, AHRQ WebM&M…
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psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - Central, not Epidural
September 1, 2011
Simmons D. Central, not Epidural. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/central-not-epidural
The Case
A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively,
he was awake, alert, and oriented to time, place,…
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psnet.ahrq.gov/node/44518/psn-pdf
January 22, 2016 - Embracing errors in simulation-based training: the effect
of error training on retention and transfer of central
venous catheter skills.
January 22, 2016
Gardner AK, Abdelfattah K, Wiersch J, et al. Embracing Errors in Simulation-Based Training: The Effect of
Error Training on Retention and Transfer of Central Ven…
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psnet.ahrq.gov/node/43304/psn-pdf
July 02, 2014 - Finding and Preventing Patient Safety Incidents.
July 2, 2014
Golden, CO: HealthGrades, Inc.; June 9, 2014.
https://psnet.ahrq.gov/issue/finding-and-preventing-patient-safety-incidents
Analyzing Medicare data from 2010 through 2012, this report discusses hospital efforts to prevent patient
harm and estimates that …
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psnet.ahrq.gov/node/73667/psn-pdf
September 01, 2021 - Cardinal Health recalls Argyle UVC insertion tray due to
missing instructions for use for the Safety Scalpel N11.
September 1, 2021
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.
https://psnet.ahrq.gov/issue/cardinal-health-recalls-argyle-uvc-insertion-tray-due-missing-i…
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psnet.ahrq.gov/node/836777/psn-pdf
March 23, 2022 - Cost of health care-associated infections in the United
States.
March 23, 2022
Forrester JD, Maggio PM, Tennakoon L. Cost of health care-associated infections in the United States. J
Patient Saf. 2022;18(2):e477-e479. doi:10.1097/pts.0000000000000845.
https://psnet.ahrq.gov/issue/cost-health-care-associated-infect…
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psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
December 01, 2014 - SPOTLIGHT CASE
Not-So-Therapeutic Tap
Citation Text:
Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/49604/psn-pdf
June 01, 2010 - Tacit Handover, Overt Mishap
June 1, 2010
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
The Case
A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3
years earlier to treat an abdo…
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psnet.ahrq.gov/node/848109/psn-pdf
April 26, 2023 - The Danger of 10% Intravenous Calcium Chloride
Extravasation.
April 26, 2023
The Danger of 10% Intravenous Calcium Chloride Extravasation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
The Case
A 52-year-old man with a history of lymphoplasmacytic lymph…
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psnet.ahrq.gov/node/866687/psn-pdf
September 11, 2024 - An exploratory analysis of the association between
healthcare associated infections & hospital financial
performance.
September 11, 2024
Beauvais B, Dolezel D, Shanmugam R, et al. An exploratory analysis of the association between
healthcare associated infections & hospital financial performance. Healthcare (Basel…