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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - Flow to device correctly adjusted accordingly, if applicable
ii. … Flow – is sweep-gas flow correctly adjusted?
ii.
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psnet.ahrq.gov/node/73553/psn-pdf
July 28, 2021 - on top of that is the assessment of when medical interventions are needed, are they done
and done correctly … So, within
that entire span of care for that individual, did we do our part in getting it set up correctly
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psnet.ahrq.gov/node/49541/psn-pdf
August 21, 2007 - Mark My Tooth
August 21, 2007
Smith RA. Mark My Tooth. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/mark-my-tooth
The Case
A 45-year-old healthy man was scheduled to have two teeth extracted for progressive dental caries. The
patient underwent the extractions, awoke from the anesthesia, and then realized…
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psnet.ahrq.gov/node/73901/psn-pdf
September 29, 2021 - Handshake antimicrobial stewardship as a model to
recognize and prevent diagnostic errors
September 29, 2021
Searns JB, Williams MC, MacBrayne CE, et al. Handshake antimicrobial stewardship as a model to
recognize and prevent diagnostic errors. Diagnosis (Berl). 2020;8(3):347-352. doi:10.1515/dx-2020-0032.
https:/…
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …
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psnet.ahrq.gov/node/60543/psn-pdf
May 27, 2020 - This helps ensure that one
has heard and transcribed an order correctly.
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psnet.ahrq.gov/node/862983/psn-pdf
February 28, 2024 - Airway Obstruction during Anterior Cervical Spine
Surgery
February 28, 2024
Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
The Case
A 47-year-old obese man (body weight 13…
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psnet.ahrq.gov/web-mm/central-not-epidural
August 28, 2024 - Central, not Epidural
Citation Text:
Simmons D. Central, not Epidural. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
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psnet.ahrq.gov/issue/tips-safer-surgery
December 22, 2021 - Fact Sheet/FAQs
Tips for Safer Surgery.
Citation Text:
Tips for Safer Surgery. Surgical Care Improvement Project. Oklahoma City, OK: Oklahoma Foundation for Medical Quality; 2006.
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…
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psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - Central, not Epidural
September 1, 2011
Simmons D. Central, not Epidural. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/central-not-epidural
The Case
A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively,
he was awake, alert, and oriented to time, place,…
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psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - Mixup Beyond the Medication Label
August 1, 2018
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
The Case
An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another
hospi…
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psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - The pediatrician in this case correctly assumed that the parent might not understand simple written or
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psnet.ahrq.gov/node/33815/psn-pdf
September 01, 2016 - detect
melanoma by using it to evaluate 93 photos of biopsy-proven melanoma.(12) Disconcertingly, it correctly
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psnet.ahrq.gov/node/33651/psn-pdf
June 01, 2007 - Are pressure ulcers not being discovered, or are they not
being correctly staged so that people know
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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac
Arrest
September 30, 2020
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
Disclosure of Relevant Financial Relationships: As a pr…
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psnet.ahrq.gov/node/49682/psn-pdf
April 01, 2013 - From Possible to Probable to Sure to Wrong—Premature
Closure and Anchoring in a Complicated Case
April 1, 2013
Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a
Complicated Case. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premat…
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/issue/improving-reliability-root-cause-analysis
January 17, 2017 - Newspaper/Magazine Article
Improving reliability with root cause analysis.
Citation Text:
Improving reliability with root cause analysis. Latino RJ
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psnet.ahrq.gov/node/854848/psn-pdf
October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures
October 31, 2023
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
The Case
A 32-year-old man presented to the hospital with…
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psnet.ahrq.gov/web-mm/one-dose-two-errors
September 29, 2017 - Further review revealed that the information about the positive yeast culture had been correctly called