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psnet.ahrq.gov/node/49842/psn-pdf
September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric
Emergency Equipment
September 1, 2018
Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet
[internet]. 2018.
https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
The Case
As part of…
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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/sites/default/files/import/webmm.ahrq.gov.128_slideshow.ppt
July 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case July 2006
Moving Pains
Source and Credits
This presentation is based on the June/July 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Hildy Schell, RN, MS, CCRN, CCNS, and…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
December 01, 2010 - Spotlight Case July 2008
Spotlight Case
The Forgotten Turn
*
*
Source and Credits
This presentation is based on the December 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Susan Barbour, RN, FNP, University of California San Francisco …
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psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
June 14, 2023 - January 19, 2022
A conceptual framework to reduce inpatient preventable deaths.
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psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
December 02, 2020 - diagnosing PE can sometimes prove challenging.( 5 )
While PE can be fatal and is responsible for 180,000 deaths
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psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - -
skin cancer among women in the US, breast cancer accounted for 250,520 new diagnoses and 42,000
deaths
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psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
September 09, 2013 - Double Dose at Transfer
May 1, 2012
Surveying care teams after in-hospital deaths
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - causes of maternal mortality in the United States,
accounting for 9 to 11 percent of pregnancy-related deaths
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - during their lifetimes.13 It is estimated that diagnostic
errors are responsible for 40,000-80,000 deaths
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - Alarm fatigue has resulted in missed
patient events and preventable deaths.
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psnet.ahrq.gov/node/33803/psn-pdf
January 01, 2015 - than would have occurred if the
2010 rate had remained unchanged, and, more importantly, 87,000 fewer deaths
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psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
February 26, 2025 - The To Err Is Human report identified deaths occurring in the American health care system because
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psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to
Complications and Poor Follow-up
July 31, 2023
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications
and poor follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restricti…
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psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
September 01, 2016 - One concerning study reviewed 32 cases that ended in catastrophic outcomes, including deaths and malpractice
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psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - efforts are part of a larger challenge, many with “zero” as their goals, such as “Vision Zero” to reduce deaths
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psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - Lethal Cap
Citation Text:
Schillinger D. Lethal Cap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Do…
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psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - Situational Awareness and Patient Safety
April 1, 2016
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
The Case
A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…
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psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma
February 26, 2025 - In Conversation With… Lorri Zipperer, MA
November 1, 2015
Citation Text:
In Conversation With… Lorri Zipperer, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
For…
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psnet.ahrq.gov/node/33773/psn-pdf
September 01, 2014 - Overuse as a Patient Safety Problem
September 1, 2014
Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem
Perspective
Nearly half of primary care physicians in the United States believe that patients cared for in their own
prac…