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psnet.ahrq.gov/node/866826/psn-pdf
September 25, 2024 - Hypoxic Gas Supply from Cross-Connected Pipelines
September 25, 2024
Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
The Case
An 8-year-old boy with no significant past medical…
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psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
May 01, 2018 - SPOTLIGHT CASE
Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency
Citation Text:
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
January 13, 2010 - SPOTLIGHT CASE
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
Citation Text:
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - SPOTLIGHT CASE
All in the History
Citation Text:
Fee C. All in the History. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
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psnet.ahrq.gov/node/866618/psn-pdf
December 31, 2024 - A Fatal Twist in Pseudohyperkalemia
December 31, 2024
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council
for C…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - SPOTLIGHT CASE
Delayed Diagnosis of Mesenteric Ischemia
Citation Text:
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Format:
…
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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care
Anita L. Tucker, DBA, MS | August 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSN…
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psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
January 01, 2016 - In Conversation With… Mark L. Graber, MD
January 1, 2016
Also Read an Essay
Citation Text:
In Conversation With… Mark L. Graber, MD. 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/conversation-hardeep-singh-md-mph
January 01, 2014 - In Conversation With… Hardeep Singh, MD, MPH
December 1, 2013
Also Read an Essay
Also Read an Essay
Citation Text:
In Conversation With… Hardeep Singh, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Heal…
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psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
February 01, 2019 - In Conversation With… Susan E. Skochelak, MD, PhD
February 1, 2019
Also Read an Essay
Citation Text:
In Conversation With… Susan E. Skochelak, MD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
November 25, 2020 - EMS Perils from Hospital Overcrowding
Citation Text:
Brown S, Rose JS, Barnes DK. EMS Perils from Hospital Overcrowding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Format:
Google Scholar BibTeX E…
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - SPOTLIGHT CASE
Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome
Citation Text:
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet…
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS
August 1, 2009
Also Read an Essay
Citation Text:
In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.In Conversation with...Steven J. Spear, DBA, MS, MS . PSNet [internet]. Rockville (MD…
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psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
January 01, 2024 - Spotlight
Spotlight
Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis
1
Source and Credits
This presentation is based on the December 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Comment…
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psnet.ahrq.gov/node/836850/psn-pdf
March 31, 2022 - A recent report on nursing education
curricula examined the safety and medication administration practice
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psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
March 30, 2020 - Also, there is the fact that we examined patient safety across the care delivery system.
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psnet.ahrq.gov/node/846975/psn-pdf
March 28, 2023 - From the ACOG perspective, topics such as payer models can be critically examined to determine whether
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psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
March 30, 2020 - Also, there is the fact that we examined patient safety across the care delivery system.
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - Research posted on PSNet in 2023 examined how adverse events affect HCWs psychologically and how they
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - We have examined what we refer to as reliability-enhancing work practices that shape the
selection and