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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73456/psn-pdf
    June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia June 30, 2021 Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…
  2. psnet.ahrq.gov/web-mm/double-trouble
    August 01, 2012 - SPOTLIGHT CASE Double Trouble Citation Text: Gurwitz JH. Double Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
  3. psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
    October 19, 2022 - SPOTLIGHT CASE Resuscitation Errors: A Shocking Problem Citation Text: Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49669/psn-pdf
    November 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.…
  5. psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
    January 01, 2024 - The Different Count Contributions to Retention Differential Count Contributions in Retained Surgical Sponge Cases: Examination of Administrative Penalty Cases from the California Department of Public Health (CDPH), Health and Safety Code Section 1280.1 Enforcement Reports from 2007-2014 A NoThing Left Behin…
  6. psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
    February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency Citation Text: Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33702/psn-pdf
    November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH November 1, 2010 In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49584/psn-pdf
    April 01, 2009 - EMR Entry Error: Not So Benign April 1, 2009 Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign The Case A 47-year-old man with advanced AIDS was admitted to an academic medical center with a chief complaint of shortness of breath. He was …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838855/psn-pdf
    October 27, 2022 - False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. October 27, 2022 Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49760/psn-pdf
    May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854897/psn-pdf
    October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose October 31, 2023 Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/weight-and-…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846768/psn-pdf
    March 29, 2023 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. March 29, 2023 Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery The Ca…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33754/psn-pdf
    September 01, 2013 - In Conversation With… Sidney Dekker, MA, MSc, PhD September 1, 2013 In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd Editor's note: Sidney Dekker is Professor and Director of the Safety Science Innovation Lab at Grif…
  14. psnet.ahrq.gov/web-mm/discharging-our-responsibility
    January 16, 2019 - Discharging Our Responsibility Citation Text: Fonarow GC. Discharging Our Responsibility. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
  15. psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
    March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose Citation Text: Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837659/psn-pdf
    July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging July 8, 2022 Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging The Cases Case #1: A 42-year-old woman admitted with…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33723/psn-pdf
    December 01, 2011 - Implementing a Fall Prevention Program December 1, 2011 Healey F. Implementing a Fall Prevention Program. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/implementing-fall-prevention-program Perspective Throughout the developed world, most hospital beds are occupied by older people, many of whom have b…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50949/psn-pdf
    February 26, 2020 - Pre-analytical pitfalls: Missing and mislabeled specimens February 26, 2020 Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens The Case Case #1: A 56-year-old man was admitted to…
  19. psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx Spotlight Code Status vs. Care Status Source and Credits • This presentation is based on the December 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Rebe…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49602/psn-pdf
    April 01, 2010 - Anticoagulation: Held Too Long April 1, 2010 Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/anticoagulation-held-too-long The Case A 68-year-old woman with a history of mitral valve replacement with a mechanical valve was admitted with abdominal pain. Because of the…

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