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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.
Citation Text:
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
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psnet.ahrq.gov/node/33837/psn-pdf
July 01, 2017 - In Conversation With… Michelle Mello, MPhil, JD, PhD
July 1, 2017
In Conversation With… Michelle Mello, MPhil, JD, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
Editor's note: Michelle Mello is Professor of Law at Stanford Law School and Professor of Healt…
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psnet.ahrq.gov/node/865412/psn-pdf
March 27, 2024 - Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
March 27, 2024
Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a
Psychiatric Presentation. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatmen…
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psnet.ahrq.gov/node/33680/psn-pdf
March 22, 2009 - In Conversation with...Dean Schillinger, MD
March 22, 2009
In Conversation with..Dean Schillinger, MD. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
Editor's note: Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco,
Directo…
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psnet.ahrq.gov/node/866055/psn-pdf
May 29, 2024 - Reducing Preventable Patient Harm Due to Retained
Surgical Items: The RSI Bundle
May 29, 2024
https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
Summary
Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common
catego…
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psnet.ahrq.gov/web-mm/empty-bag
June 01, 2018 - The Empty Bag
Citation Text:
Vincent C. The Empty Bag. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/72835/psn-pdf
March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy
March 10, 2021
In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family
Cente…
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psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - All in the History
March 21, 2009
Fee C. All in the History. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/all-history
Case Objectives
Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it
does not apply to transfers to emergency departments from non-acute care faci…
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psnet.ahrq.gov/node/73526/psn-pdf
July 28, 2021 - Medication Errors in Retail Pharmacies: Wrong Patient,
Wrong Instructions.
July 28, 2021
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
The Case
…
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psnet.ahrq.gov/node/49744/psn-pdf
October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced
Hemolysis in a Patient With a Known Allergy
October 1, 2015
Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known
Allergy. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
March 27, 2024
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and
Emergency Hysterectomy. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
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psnet.ahrq.gov/node/49765/psn-pdf
August 21, 2016 - Cognitive Overload in the ICU
August 21, 2016
Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/cognitive-overload-icu
Case Objectives
Identify the role of cognitive overload—especially interruptions—in compromising quality of care and
patient safety.
List…
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - What Happened on Telemetry?
April 1, 2019
Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/what-happened-telemetry
Case Objectives
Describe current hospital practices for continuous telemetry monitoring.
Appreciate key recommendations from the Update to Practice…
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psnet.ahrq.gov/node/33803/psn-pdf
January 01, 2015 - In Conversation With… Richard Kronick, PhD
February 1, 2014
In Conversation With… Richard Kronick, PhD. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
Editor's note: Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since
August 2013 …
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psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping
Healthcare Providers
May 26, 2021
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
The Case
…
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psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - Hidden Mystery
March 1, 2005
Brunette DD. Hidden Mystery. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hidden-mystery
Case Objectives
Appreciate the challenges of caring for morbidly obese patients.
List specific interventions that can be implemented when caring for obese patients.
Develop a rational ap…
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the
Senior Clinical Data Analyst at Atrium Health, and Rhonda
Dickman, MSN, RN, CPHQ, the Director of the Tennessee
Hospital Association PSO
January 12, 2022
In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and
Rhonda…
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psnet.ahrq.gov/node/49666/psn-pdf
October 01, 2012 - CA-MRSA Skin Infections: An Ounce of Prevention is
Worth a Pound of Cure
October 1, 2012
Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet].
2012.
https://psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
Case Objectives
Identify risk f…
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …