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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846768/psn-pdf
    March 29, 2023 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. March 29, 2023 Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery The Ca…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33841/psn-pdf
    September 01, 2017 - In Conversation With… Andrew Gettinger, MD September 1, 2017 In Conversation With… Andrew Gettinger, MD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md Editor's note: Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the Office of Cli…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49508/psn-pdf
    January 01, 2007 - Language Barrier April 1, 2006 Flores G. Language Barrier. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/language-barrier The Case A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish- speaking parents when they noted that their daughter had generalized we…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49654/psn-pdf
    June 01, 2012 - Transfer Troubles June 1, 2012 Hains IM. Transfer Troubles. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfer-troubles Case Objectives Recognize that transfer of patients between hospitals is common. Understand the frequency of errors and adverse events in the transfer of patients between hospitals. …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33805/psn-pdf
    April 01, 2016 - In Conversation With… Thomas J. Nasca, MD, MACP April 1, 2016 In Conversation With… Thomas J. Nasca, MD, MACP. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp Editor's note: Dr. Nasca is Chief Executive Officer of the Accreditation Council for Graduate Medical Educat…
  6. 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 …
  7. 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…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33807/psn-pdf
    May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD May 1, 2016 In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd Editor's note: Dr. Drew, a nurse researcher, is the David Mortara Distinguished Professor of Physiological Nursing and…
  9. psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
    September 15, 2024 - COVID-19: Team and Human Factors to Improve Safety Citation Text: Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar…
  10. psnet.ahrq.gov/web-mm/code-blue-where
    March 30, 2020 - Code Blue—Where To? Citation Text: Adams BD. Code Blue—Where To?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
  11. 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 …
  12. psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
    February 23, 2022 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement Citation Text: Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
  13. psnet.ahrq.gov/primer/medication-administration-errors
    December 15, 2024 - Medication Administration Errors Citation Text: MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X…
  14. psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
    July 23, 2024 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 31, 2023 Innovation Contact …
  15. psnet.ahrq.gov/primer/failure-rescue
    September 15, 2024 - Failure to Rescue Citation Text: Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…
  16. psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Jaenic Lee, MD Josh Fernel…
  17. psnet.ahrq.gov/web-mm/techno-trip
    May 01, 2005 - Techno Trip Citation Text: Cook RI. Techno Trip. 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 Downlo…
  18. psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
    January 29, 2021 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. Citation Text: Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
  19. psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
    January 01, 2024 - Spotlight Spotlight A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis 1 Source and Credits This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Garth Utter, MD, MSc, FACS…
  20. psnet.ahrq.gov/web-mm/failure-latch
    November 27, 2012 - Failure to Latch Citation Text: Rodriguez M, Mannel R, Frye DR. Failure to Latch. 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 Endnote tag…

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