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  1. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-279
    February 10, 2021 - February 17, 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, repor…

  2. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
    January 01, 2022 - Spotlight Spotlight Intraosseous Line Extravasation in a Pediatric Trauma Patient Source and Credits • This presentation is based on the April 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: David Barnes, MD and Joseph Yoon, MD o…

  3. EHR Copy and Paste and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
    January 01, 2018 - EHR Copy and Paste and Patient Safety Shannon M. Dean, MD | January 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare…

  4. WebM&M Cases & Commentaries | PSNet

    psnet.ahrq.gov/Webmm
    May 01, 2021 - WebM&M Cases & Commentaries WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by…

  5. Webmm

    psnet.ahrq.gov/webmm
    May 01, 2021 - WebM&M Cases & Commentaries WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74242/psn-pdf
    January 07, 2022 - The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps January 7, 2022 Sauder C, Kleber KT. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps The Case A 52-year-old woman w…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866261/psn-pdf
    July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery July 10, 2024 Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…

  8. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-296
    June 30, 2021 - June 16, 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, reports, …

  9. May I Have Another?—Medication Error | PSNet

    psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
    March 01, 2009 - May I Have Another?—Medication Error Citation Text: Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49774/psn-pdf
    November 01, 2016 - Don't Dismiss the Dangerous: Obstetric Hemorrhage November 1, 2016 Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage Case Objectives List the common causes of obstetric hemorrhage and the need for a unit-sta…

  11. Don't Dismiss the Dangerous: Obstetric Hemorrhage | PSNet

    psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
    August 21, 2024 - SPOTLIGHT CASE Don't Dismiss the Dangerous: Obstetric Hemorrhage Citation Text: Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49490/psn-pdf
    September 01, 2005 - The Wrong Channel September 1, 2005 Gosbee JW. The Wrong Channel . PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/wrong-channel The Case A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial dosing started at 50 mL/hour using a multi-channel medication pump…

  13. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-382
    March 15, 2023 - March 15, 2023 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, reports,…

  14. Urinary Retention Dilemma | PSNet

    psnet.ahrq.gov/web-mm/urinary-retention-dilemma
    March 01, 2013 - Urinary Retention Dilemma Citation Text: Joseph AC. Urinary Retention Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

  15. Discharge Instructions in the PACU: Who Remembers? | PSNet

    psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
    August 05, 2009 - Discharge Instructions in the PACU: Who Remembers? Citation Text: Engel KG. Discharge Instructions in the PACU: Who Remembers?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar B…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74253/psn-pdf
    January 12, 2022 - Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic January 12, 2022 Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/patient…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836976/psn-pdf
    April 27, 2022 - Intraosseous Line Extravasation in a Pediatric Trauma Patient April 27, 2022 Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient Disclosure of Relevant Financial Relationship…

  18. Monitoring Fetal Health | PSNet

    psnet.ahrq.gov/web-mm/monitoring-fetal-health
    September 08, 2010 - SPOTLIGHT CASE Monitoring Fetal Health Citation Text: Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNot…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843051/psn-pdf
    February 01, 2023 - Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. February 1, 2023 Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-…

  20. Difficult Encounters: A CMO and CNO Respond | PSNet

    psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
    March 01, 2018 - SPOTLIGHT CASE Difficult Encounters: A CMO and CNO Respond Citation Text: Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: …
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