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psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
May 01, 2012 - Situational Awareness and Patient Safety
Citation Text:
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Annual Perspective
Handoffs and Transitions
Niraj Sehgal, MD, MPH | January 22, 2014
View more articles from the same authors.
Citation Text:
Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/web-mm/transition-nowhere
March 21, 2009 - Transition to Nowhere
Citation Text:
Farrell TW. Transition to Nowhere. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/specimen-almost-lost
September 21, 2022 - Specimen Almost Lost
Citation Text:
Hehe YK. Specimen Almost Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49536/psn-pdf
May 01, 2007 - On the Other Hand
May 1, 2007
Henneman EA. On the Other Hand. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/other-hand
The Case
A young woman with Takayasu's arteritis presented to the hospital with severe abdominal pain. The patient
had been diagnosed with Takayasu's a decade earlier. The disease results…
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psnet.ahrq.gov/web-mm/suicide-risk-hospital
November 01, 2011 - Suicide Risk in the Hospital
Citation Text:
Mills PD. Suicide Risk in the Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/surprise-wire
July 15, 2020 - Surprise Wire
Citation Text:
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/carpe-diem-seize-day
September 01, 2012 - Carpe Diem (Seize the Day)
Citation Text:
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - The Dangerous Detour
Citation Text:
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room
Citation Text:
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…
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psnet.ahrq.gov/node/50701/psn-pdf
November 26, 2019 - In Conversation With... Heidi Wald, MD
November 26, 2019
In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-heidi-wald-md
Editor’s note: Dr. Wald, MD, MSPH, is the Chief Quality and Safety Officer at SCL Health in Denver, CO.
She has previously served as …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
July 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case July 2007
Resuscitation Errors:
A Shocking Problem
Source and Credits
This presentation is based on the July 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Benjamin Abella, MD, MPhil, …
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psnet.ahrq.gov/node/49674/psn-pdf
December 01, 2012 - Preventing PICC Complications: Whose Line Is It?
December 1, 2012
Moureau N. Preventing PICC Complications: Whose Line Is It? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
The Case
A 55-year-old woman with myasthenia gravis, hypertension, and hypothyroidism prese…
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in
the Operating Room
October 27, 2021
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
…
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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…
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psnet.ahrq.gov/node/33646/psn-pdf
February 01, 2007 - In Conversation with...Joseph Britto, MD
February 1, 2007
In Conversation with..Joseph Britto, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
Editor's Note: Joseph Britto, MD, is CEO and Co-founder of Isabel Healthcare Inc. Isabel, a clinical
decision support syste…
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psnet.ahrq.gov/node/33823/psn-pdf
January 01, 2017 - Workplace Safety in Health Care
January 1, 2017
Simon RW, Canacari EG. Workplace Safety in Health Care. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/workplace-safety-health-care
Perspective
The patient safety movement has highlighted the risks that patients face when receiving health care. But,
impo…
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psnet.ahrq.gov/node/50859/psn-pdf
January 31, 2020 - In Conversation With... David Gruen, MD
January 31, 2020
In Conversation With.. David Gruen, MD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-david-gruen-md
Editor’s note: David R. Gruen, MD, MBA, FACR is the Chief Medical Officer, Imaging at IBM Watson
Health and is a thought leader and…
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psnet.ahrq.gov/node/74253/psn-pdf
January 12, 2022 - Patient Safety Events and the Role of Patient Safety
Organizations During the COVID-19 Pandemic
January 12, 2022
Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and the Role of Patient Safety Organizations
During the COVID-19 Pandemic. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/patient…
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - 40 of K
November 1, 2003
Lesar TS. 40 of K. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/40-k
The Case
An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve
replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…