-
psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - Failure to do so can lead to tracheal and surrounding structure damage with severe clinical consequences
-
psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - how, unfortunately, tracheostomy management is often overlooked, and such errors can lead to grave consequences
-
psnet.ahrq.gov/node/867022/psn-pdf
October 30, 2024 - untreated, the patient will eventually develop focal neurological
deficits, often with devastating consequences
-
psnet.ahrq.gov/node/49714/psn-pdf
August 21, 2014 - opportunity to focus on necrotizing fasciitis as this diagnosis is often missed or
delayed with devastating consequences
-
psnet.ahrq.gov/node/49768/psn-pdf
September 01, 2016 - Clinical consequences of polypharmacy in elderly. Expert Opin Drug
Saf. 2014;13:57-65.
-
psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - illustrates, missing an acute medical condition puts a
psychiatry inpatient–bound patient at risk for severe consequences
-
psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
February 26, 2025 - But, there are consequences.
-
psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
February 26, 2025 - The snails said we should study this because there are opportunity costs, unintended consequences, etc
-
psnet.ahrq.gov/node/33706/psn-pdf
February 01, 2011 - What the Journal did not allow
us to publish was the cost consequences of massively reducing our postoperative
-
psnet.ahrq.gov/node/33783/psn-pdf
April 01, 2015 - One sad thing about patient safety is the consequences
are borne almost entirely by the patient.
-
psnet.ahrq.gov/periodic-issue/periodic-issue-276
January 29, 2021 - January 27, 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, report…
-
psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - All in the History
March 21, 2009
Fee C. All in the History. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/all-history
Case Objectives
Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it
does not apply to transfers to emergency departments from non-acute care faci…
-
psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - SPOTLIGHT CASE
Signout Fallout
Citation Text:
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote…
-
psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment
Citation Text:
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citatio…
-
psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound
and Patient Safety
July 1, 2018
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
Case Objectives
Unders…
-
psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
March 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Interdisciplinary teamwork
Download
Share
Facebook
Twitter
Linkedin
Copy URL
Subscribe
Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet T…
-
psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
April 27, 2022 - SPOTLIGHT CASE
CME/MOC
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.
Citation Text:
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSN…
-
psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
August 31, 2022 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?
Citation Text:
Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
-
psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
Linkedin
Copy URL
March 3, 2021
Innovation…
-
psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - Sudden Collapse During Upper Gastrointestinal
Endoscopy: Expect the Unexpected
August 25, 2021
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-
unexpected
…