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321. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest | PSNet
     psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
     April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest Citation Text: Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…

322. Redesigning hospital alarms for patient safety: alarmed and potentially dangerous. | PSNet
     psnet.ahrq.gov/issue/redesigning-hospital-alarms-patient-safety-alarmed-and-potentially-dangerous
     December 12, 2018 - Commentary Redesigning hospital alarms for patient safety: alarmed and potentially dangerous. Citation Text: Chopra V, McMahon LF. Redesigning hospital alarms for patient safety: alarmed and potentially dangerous. JAMA. 2014;311(12):1199-200. doi:10.1001/jama.2014.710. Copy Citation …

323. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42853/psn-pdf
     January 15, 2014 - Eliminating central line-associated bloodstream infections: a national patient safety imperative. January 15, 2014 Berenholtz SM, Lubomski LH, Weeks K, et al. Eliminating central line-associated bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidemiol. 2014;35(1):56-62. doi:10.108…

324. Tubing misconnections: normalization of deviance. | PSNet
     psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance
     December 16, 2015 - Review Tubing misconnections: normalization of deviance. Citation Text: Simmons D, Symes L, Guenter P, et al. Tubing misconnections: normalization of deviance. Nutr Clin Pract. 2011;26(3):286-293. doi:10.1177/0884533611406134. Copy Citation Format: DOI Google Scholar PubM…

325. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/843736/psn-pdf
     February 01, 2023 - Saved by ECMO February 1, 2023 Weiss NA. Saved by ECMO . PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/saved-ecmo The Case A 27-year-old pregnant woman was admitted at an estimated gestational age (EGA) of 29 weeks for increased shortness of breath. She was diagnosed with severe pulmonary arterial hyperte…

326. Avoidable iatrogenic complications of urethral catheterization and inadequate intern training in a tertiary-care teaching hospital. | PSNet
     psnet.ahrq.gov/issue/avoidable-iatrogenic-complications-urethral-catheterization-and-inadequate-intern-training
     March 02, 2011 - Study Avoidable iatrogenic complications of urethral catheterization and inadequate intern training in a tertiary-care teaching hospital. Citation Text: Thomas AZ, Giri SK, Meagher D, et al. Avoidable iatrogenic complications of urethral catheterization and inadequate intern training i…

327. The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database. | PSNet
     psnet.ahrq.gov/issue/nature-magnitude-and-reporting-compliance-device-related-events-intravenous-patient
     March 20, 2024 - Study The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database. Citation Text: Lawal OD, Mohanty M, Elder H, et al. The nature, magnitude, and reporti…

328. Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature. | PSNet
     psnet.ahrq.gov/issue/overlooked-guide-wire-multicomplicated-swiss-cheese-model-example-analysis-case-and-review
     September 15, 2021 - Commentary Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature. Citation Text: Thonon H, Espeel F, Frederic F, et al. Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of t…

329. Sources of nurse-sensitive inpatient safety improvement. | PSNet
     psnet.ahrq.gov/issue/sources-nurse-sensitive-inpatient-safety-improvement
     July 07, 2021 - Study Sources of nurse-sensitive inpatient safety improvement. Citation Text: Dynan L, Smith RB. Sources of nurse‐sensitive inpatient safety improvement. Health Serv Res. 2022;57(6):1235-1246. doi:10.1111/1475-6773.13979. Copy Citation Format: DOI Google Scholar BibTeX EndN…

330. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44355/psn-pdf
     September 02, 2015 - Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures. September 2, 2015 Shaw SJ, Jacobs B, Stockwell DC, et al. Effect of a Real-Time Pediatric ICU Safety Bundle Dashboard on Quality Improvement Measures. Jt Comm J Qual Patient Saf. 2015;41(9):414-420. https://psnet.ahrq.gov/…

331. A Call to Action: Experience in Adopting the ENFit System to Guard Against Accidental Tubing Misconnections. | PSNet
     psnet.ahrq.gov/issue/call-action-experience-adopting-enfit-system-guard-against-accidental-tubing-misconnections
     February 03, 2021 - Meeting/Conference Upcoming Meeting/Conference Published February 3, 2021 A Call to Action: Experience in Adopting the ENFit System to Guard Against Accidental Tubing Misconnections. Institute for Safe Medication Practices. February 24, 2021, 1:00--2:00 PM (eastern).  Topics Approach to Improving Safety Forcing …

332. Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. | PSNet
     psnet.ahrq.gov/issue/implementing-robust-process-improvement-program-neonatal-intensive-care-unit-reduce-harm
     March 23, 2022 - Study Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. Citation Text: Nether KG, Thomas EJ, Khan A, et al. Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. J Healthc Qual. 2022;44(1)…

333. Central Line Insertion Care Team Checklist. | PSNet
     psnet.ahrq.gov/issue/central-line-insertion-care-team-checklist
     October 02, 2024 - Toolkit Central Line Insertion Care Team Checklist. Citation Text: Agency for Healthcare Research and Quality. Central Line Insertion Care Team Checklist. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download…

334. Toolkit for Decolonization of Non-ICU Patients with Devices. | PSNet
     psnet.ahrq.gov/issue/toolkit-decolonization-non-icu-patients-devices
     November 15, 2023 - Toolkit Toolkit for Decolonization of Non-ICU Patients with Devices. Citation Text: Agency for Healthcare Research and Quality. Toolkit for Decolonization of Non-ICU Patients with Devices. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…

335. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49734/psn-pdf
     May 01, 2015 - Departure From Central Line Ritual May 1, 2015 Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/departure-central-line-ritual The Case A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…

336. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33751/psn-pdf
     January 01, 2014 - Strengthening the Business Case for Patient Safety May 1, 2013 Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety Perspective After more than a decade in the national spotlight, the problem of pati…

337. ALERT: reports of severe harm after intravenous administration of breast milk to infants. | PSNet
     psnet.ahrq.gov/issue/alert-reports-severe-harm-after-intravenous-administration-breast-milk-infants
     May 02, 2018 - Newspaper/Magazine Article ALERT: reports of severe harm after intravenous administration of breast milk to infants. Citation Text: ALERT: reports of severe harm after intravenous administration of breast milk to infants. ISMP Canada Safety Bulletin. July 31, 2011;11:1-2.   …

338. Preventing infections: how Portland hospitals compare. | PSNet
     psnet.ahrq.gov/issue/preventing-infections-how-portland-hospitals-compare
     June 08, 2011 - Newspaper/Magazine Article Preventing infections: how Portland hospitals compare. Citation Text: Preventing infections: how Portland hospitals compare. Rojas-Burke J. The Oregonian. May 8, 2010. Copy Citation Save Save to your library Print Download P…

339. Impact of rounding checklists on the outcomes of patients admitted to ICUs: a systematic review and meta-analysis. | PSNet
     psnet.ahrq.gov/issue/impact-rounding-checklists-outcomes-patients-admitted-icus-systematic-review-and-meta
     July 03, 2016 - Review Impact of rounding checklists on the outcomes of patients admitted to ICUs: a systematic review and meta-analysis. Citation Text: MacKinnon KM, Seshadri S, Mailman JF, et al. Impact of rounding checklists on the outcomes of patients admitted to ICUs: a systematic review and meta-a…

340. Assuring safe patient care in a level III NICU in anticipation of hospital closure. | PSNet
     psnet.ahrq.gov/issue/assuring-safe-patient-care-level-iii-nicu-anticipation-hospital-closure
     April 22, 2016 - Study Assuring safe patient care in a level III NICU in anticipation of hospital closure. Citation Text: Fleishman R, Anday E, Bhandari V. Assuring safe patient care in a level III NICU in anticipation of hospital closure. J Perinatol. 2020. doi:10.1038/s41372-020-0648-7. Copy Citation…