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9701. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49719/psn-pdf
      September 01, 2014 - No BP During NIBP September 1, 2014 Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/no-bp-during-nibp The Case An otherwise healthy 49-year-old man with atrial fibrillation was scheduled for ablation in the catheterization laboratory under general endotracheal anes…

9702. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33847/psn-pdf
      August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS August 1, 2017 In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0 Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwest…

9703. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49688/psn-pdf
      August 21, 2013 - Discharge Instructions in the PACU: Who Remembers? August 21, 2013 Engel KG. Discharge Instructions in the PACU: Who Remembers? PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers The Case A 42-year-old woman was diagnosed with a torn anterior cruciate ligament (ACL) in …

9704. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49731/psn-pdf
      April 01, 2015 - Fire in the Hole!—An OR Fire April 1, 2015 Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fire-hole-or-fire The Case A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinom…

9705. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49694/psn-pdf
      October 01, 2013 - Are You Mrs. A? An Issue of Identification Over Telephone October 1, 2013 Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone The Case Mr. A was a 78-year-old man admitted with non-ST elevation…

9706. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49835/psn-pdf
      January 01, 2020 - Don't Pick the PICC July 1, 2018 McGill RL. Don't Pick the PICC. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/dont-pick-picc The Case A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy; glaucoma; and stage IV chronic kidney disease was admitted to the hospita…

9707. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72693/psn-pdf
      January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…

9708. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33884/psn-pdf
      July 01, 2019 - Emerging Safety Issues in Artificial Intelligence July 1, 2019 Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence Perspective Background Since the beginning of digital health records, there has bee…

9709. Over Not So Easy | PSNet
      psnet.ahrq.gov/web-mm/over-not-so-easy
      April 01, 2005 - Over Not So Easy Citation Text: Cucina R. Over Not So Easy. 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 PubMedId RIS …

9710. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49797/psn-pdf
      June 01, 2017 - Diagnostic Overshadowing Dangers June 1, 2017 Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers The Case A 72-year-old woman with history of opioid abuse was sent to the emergency department (ED) from a methadone clinic because she a…

9711. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50842/psn-pdf
      January 29, 2020 - Patient Identification Errors: A Systems Challenge January 29, 2020 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge The Cases The following four events involving five patients all involved…

9712. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49725/psn-pdf
      January 01, 2015 - Haste Makes Care Unsafe January 1, 2015 Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/haste-makes-care-unsafe The Case An 80-year-old man with a history of coronary artery disease and atrial fibrillation underwent a combined elective coronary artery bypass graft (CABG…

9713. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49466/psn-pdf
      October 14, 2004 - Hard to Swallow October 1, 2004 Driver J. Hard to Swallow. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/hard-swallow The Case An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, …

9714. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49637/psn-pdf
      October 01, 2011 - The Dropped "No" October 1, 2011 Johnson AJ. The Dropped "No". PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropped-no The Case A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in his legs. Because the leg swelling was somewhat more pronounced in his…

9715. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49423/psn-pdf
      November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…

9716. Psn-Pdf (pdf file)
      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…

9717. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49407/psn-pdf
      July 01, 2003 - Bleeding Risk July 1, 2003 Crowther MA. Bleeding Risk. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/bleeding-risk The Case A frail 78-year-old woman fell at home and fractured her left hip. Her past medical history included atrial fibrillation, hypertension, coronary artery disease, and stroke. The surgi…

9718. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49625/psn-pdf
      May 01, 2011 - Pocket Syringe Swap May 1, 2011 Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/pocket-syringe-swap The Case A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for postoperative pain management. Surgery proceeded uneventfully under…

9719. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50391/psn-pdf
      September 25, 2019 - Think Like a Surgeon September 25, 2019 Cooper Z. Think Like a Surgeon. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/think-surgeon The Case A patient with a history of T6 paraplegia due to a motor vehicle accident was brought to the emergency department due to delirium. He was found to be hypotensive and…

9720. Teach-Back (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teach-back-slides-final508.pdf
      June 02, 2025 - Teach-Back Teach-Back AHRQ Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Presenter Presentation Notes The Agency for Healthcare Research and Quality, or AHRQ, funded the development of a Guide to Improving Patient Safety in Primary Care Settings by…