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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/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic
January 12, 2022
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and…
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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/33724/psn-pdf
February 01, 2012 - In Conversation With… Lawrence Smith, MD
February 1, 2012
In Conversation With… Lawrence Smith, MD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
Editor's note: Lawrence G. Smith, MD, is the founding Dean of Hofstra North Shore-LIJ School of
Medicine and Executive Vice P…
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psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
June 07, 2023 - Breathe Easy: Safe Tracheostomy Management
Citation Text:
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. 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/wheres-feeding-tube
September 01, 2003 - Where's the Feeding Tube?
Citation Text:
Metheny NA, Meert KL. Where's the Feeding Tube?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/node/865374/psn-pdf
March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and
Challenges
March 27, 2024
Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
Introducti…
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room
Citation Text:
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - Late Anemia Following Rh Disease in a Newborn
Citation Text:
Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/33622/psn-pdf
November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP
November 1, 2005
In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
Editor's Note: Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare
I…
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psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - Dangerous Dialysis
October 1, 2010
Holley JL. Dangerous Dialysis . PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/dangerous-dialysis
Case Objectives
List common errors that occur in dialysis units.
Describe steps that can be taken by dialysis units to prevent these common errors.
Describe the role of the …
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psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
May 01, 2017 - Wrong Turn through Colon: Misplaced PEG
Citation Text:
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
April 24, 2018 - The Fluidity of Diagnostic "Wet Reads"
Citation Text:
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". 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/web-mm/liver-failure-after-chemotherapy-did-we-forget-something
May 01, 2019 - Liver Failure After Chemotherapy: Did We Forget Something?
Citation Text:
Lubel J. Liver Failure After Chemotherapy: Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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G…
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psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
December 21, 2022 - In Conversation with…Troyen A. Brennan, MD, JD, MPH
December 1, 2005
Citation Text:
In Conversation with…Troyen A. Brennan, MD, JD, MPH. 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/node/72618/psn-pdf
December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral
Changes Towards Medical Decisions that Improve Care
Value and Quality of Care
December 23, 2020
https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-
medical-decisions
Summary
Nudges are a change in the way choices ar…
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/environmental-safety-or
May 19, 2015 - Environmental Safety in the OR
Citation Text:
Linkin DR, Lautenbach E. Environmental Safety in the OR . 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/node/49419/psn-pdf
October 01, 2003 - The Other Side
October 1, 2003
Vincent CA. The Other Side. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/other-side
Case Objectives
List the factors contributing to wrong site surgery.
Understand the key components of the Universal Protocol for eliminating wrong site, wrong
procedure, wrong person surger…
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psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
January 05, 2017 - Discontinued Medications: Are They Really Discontinued?
Citation Text:
Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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…