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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49415/psn-pdf
    September 01, 2003 - Intubation Mishap September 1, 2003 Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/intubation-mishap Case Objectives To understand and apply a structured method of human factors case analysis To describe the key components of effective teamwork To understand the imp…

  2. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. | PSNet

    psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
    November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. Citation Text: Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …

  3. Hypoxic Gas Supply from Cross-Connected Pipelines | PSNet

    psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
    February 05, 2020 - Hypoxic Gas Supply from Cross-Connected Pipelines Citation Text: Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google S…

  4. Syringe Swap During Regional Block: A Case of Medication Error and Recovery | PSNet

    psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
    July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery Citation Text: Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

  5. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon | PSNet

    psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
    January 29, 2021 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon Citation Text: Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850361/psn-pdf
    June 14, 2023 - Critical Echocardiogram Result Lost to Follow-up June 14, 2023 Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow The Case A 63-year-old man with history of stroke, systolic heart failure, and ventric…

  7. Patient Safety and Health Information Technology: Learning from Our Mistakes | PSNet

    psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
    July 01, 2012 - be examined independent of its implementation, or that usability remains subjective, not amenable to definition

  8. In Conversation With… David Blumenthal, MD, MPP | PSNet

    psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
    July 01, 2012 - be examined independent of its implementation, or that usability remains subjective, not amenable to definition

  9. Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions | PSNet

    psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
    November 16, 2022 - The dual objective that I was talking about earlier in the definition of HFE is part of our SEIPS models

  10. First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit | PSNet

    psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
    October 30, 2019 - The definition of an ICU is the ability to staff one nurse to one patient.

  11. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis | PSNet

    psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
    March 09, 2022 - discectomy to 35% in a single retrospective study. 8 , 9 Pathophysiology Intraoperative durotomy, by definition

  12. Intubation Mishap | PSNet

    psnet.ahrq.gov/web-mm/intubation-mishap
    April 26, 2023 - SPOTLIGHT CASE Intubation Mishap Citation Text: Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

  13. In Conversation With… Linda Aiken, PhD, RN | PSNet

    psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
    March 01, 2018 - In Conversation With… Linda Aiken, PhD, RN March 1, 2018  Also Read an Essay Citation Text: In Conversation With… Linda Aiken, PhD, RN. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60328/psn-pdf
    May 27, 2020 - Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression May 27, 2020 Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory- …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/84413/psn-pdf
    February 23, 2022 - A Loss of Trust and a Missed Diagnosis February 23, 2022 Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counci…

  16. The Need to Eat | PSNet

    psnet.ahrq.gov/web-mm/need-eat
    February 10, 2021 - The Need to Eat Citation Text: Widaman AM. The Need to Eat. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  17. In Conversation With… Wanda Pratt, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
    November 01, 2017 - In Conversation With… Wanda Pratt, PhD November 1, 2017  Also Read an Essay Citation Text: In Conversation With… Wanda Pratt, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Cop…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50755/psn-pdf
    December 18, 2019 - The Need to Eat December 18, 2019 Widaman AM. The Need to Eat. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/need-eat The Case A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder caused by the lack of vitamin B1 – was admitted for possible aspiration pneum…

  19. In Conversation With... Anna Legreid Dopp, Pharm. D | PSNet

    psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
    June 29, 2020 - In Conversation With... Anna Legreid Dopp, Pharm. D June 29, 2020  Also Read the Essay Citation Text: In Conversation With.. Anna Legreid Dopp, Pharm. D. PSNet [internet]. 2020.In Conversation With... Anna Legreid Dopp, Pharm. D. PSNet [internet]. Rockville (MD): …

  20. In Conversation With… David Blumenthal, MD, MPP | PSNet

    psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
    March 27, 2024 - In Conversation With… David Blumenthal, MD, MPP July 1, 2012  Citation Text: In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citati…
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