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9781. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49731/psn-pdf
      April 01, 2015 - Fire in the Hole!—An OR Fire April 1, 2015 Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fire-hole-or-fire The Case A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinom…

9782. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49592/psn-pdf
      October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…

9783. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49718/psn-pdf
      January 01, 2015 - Too Much, Too Fast September 1, 2014 Tuot D. Too Much, Too Fast. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/too-much-too-fast The Case A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for fever, tachycardia, and increased respiratory secretions. H…

9784. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49725/psn-pdf
      January 01, 2015 - Haste Makes Care Unsafe January 1, 2015 Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/haste-makes-care-unsafe The Case An 80-year-old man with a history of coronary artery disease and atrial fibrillation underwent a combined elective coronary artery bypass graft (CABG…

9785. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49835/psn-pdf
      January 01, 2020 - Don't Pick the PICC July 1, 2018 McGill RL. Don't Pick the PICC. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/dont-pick-picc The Case A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy; glaucoma; and stage IV chronic kidney disease was admitted to the hospita…

9786. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49784/psn-pdf
      February 01, 2017 - Safeguarding Diagnostic Testing at the Point of Care February 1, 2017 Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care The Case A 23-year-old woman presented to the family medicine clinic for…

9787. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73515/psn-pdf
      August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents July 28, 2021 https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing- home-residents Summary The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…

9788. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49523/psn-pdf
      November 01, 2006 - Urinary Retention Dilemma November 1, 2006 Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma The Case Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy (BPH) and urinary hesitancy returned to th…

9789. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837324/psn-pdf
      July 08, 2022 - A Statewide Collaborative to Support Vaginal Birth and Reduce Unnecessary Cesarean Deliveries July 8, 2022 https://psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary- cesarean-deliveries Summary   Started in response to rising maternal morbidity and mortality rates in …

9790. Statewide Telehealth Program Enhances Access to Care, Improves Outcomes for High-Risk Pregnancies in Rural Area | PSNet
      psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
      November 13, 2024 - Statewide Telehealth Program Enhances Access to Care, Improves Outcomes for High-Risk Pregnancies in Rural Area Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 12, 2020 Innovation …

9791. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73153/psn-pdf
      April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough April 28, 2021 Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough Disclosure of Relev…

9792. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33789/psn-pdf
      August 01, 2015 - In Conversation With… Robert M. Wachter, MD August 1, 2015 In Conversation With… Robert M. Wachter, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md Editor's note: Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF, where he also …

9793. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60267/psn-pdf
      March 01, 2021 - Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health Originally published on June 12, 2020 Last updated on January 11, 2021 https://psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-h…

9794. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49483/psn-pdf
      June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…

9795. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33804/psn-pdf
      March 03, 2016 - In Conversation With… Paul McGann, MD March 1, 2016 In Conversation With… Paul McGann, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-paul-mcgann-md Editor's note: Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for Medicare & Medicaid Services (CMS). He…

9796. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60268/psn-pdf
      April 29, 2020 - Complications of ECMO During Transport April 29, 2020 Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport The Case A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with acute on chro…

9797. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer | PSNet
      psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
      February 26, 2025 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL July 31, 2023 Innovation Contact …

9798. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33559/psn-pdf
      December 15, 2024 - Medication Reconciliation December 15, 2024 Medication Reconciliation. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/medication-reconciliation PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safet…

9799. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.110_slideshow.ppt
      December 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case December 2005 Low on the Totem Pole Source and Credits This presentation is based on the Dec. 2005 Spotlight Case in Surgery/Anesthesia See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Robert Wachter, MD, …

9800. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33604/psn-pdf
      December 15, 2024 - Pharmacist's Role in Medication Safety December 15, 2024 The Pharmacist's Role in Medication Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current res…