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psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - We also conducted an extensive literature review.
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
June 28, 2023
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue
Necrosis and Cuff Rupture. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…
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psnet.ahrq.gov/node/50931/psn-pdf
February 26, 2020 - repair, even if the perforation were unrecognized for more
than 24 hours.9 Certain factors, such as extensive
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psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
January 01, 2021 - Spotlight
Spotlight
An Inadvertent Bolus of Norepinephrine
Source and Credits
• This presentation is based on the May 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarina Fazio, PhD, RN, Emma Blackmon, PhD,
RN, Amy Doroy, PhD,…
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psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
January 07, 2015 - implementation is a complex sociotechnical process that requires a robust culture of safety as well as extensive
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psnet.ahrq.gov/issue/families-partners-hospital-error-and-adverse-event-surveillance
December 19, 2018 - Study
Classic
Families as partners in hospital error and adverse event surveillance.
Citation Text:
Khan A, Coffey M, Litterer KP, et al. Families as Partners in Hospital Error and Adverse Event Surveillance. JAMA Pediatr. 2017;171(4):372-381. doi:10.1001/jamape…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
August 01, 2009 - Despite extensive resuscitation attempts, the previously “stable” ICU patient was pronounced dead.
*
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psnet.ahrq.gov/node/49656/psn-pdf
June 01, 2012 - tomography (CT) angiogram was done, which was negative for pulmonary embolism but showed
much more extensive
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psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - Despite extensive diagnostic workup during the current
admission, physicians could not identify the
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - SPOTLIGHT CASE
An Inadvertent Bolus of Norepinephrine.
Citation Text:
Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citation
F…
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psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - Twelve hours later, she developed extensive thrombosis associated with the catheter and sheath site that
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psnet.ahrq.gov/node/843736/psn-pdf
February 01, 2023 - Multidisciplinary Team
While the initiation of VA-ECMO can be life-saving, it requires both a skilled team and an extensive
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - SPOTLIGHT CASE
Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture
Citation Text:
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - After extensive discussion, his family eventually decided to pursue comfort measures only, and he died
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psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
January 01, 2014 - He has conducted extensive multidisciplinary research supported by the VA, AHRQ, and NIH and is now a
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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - Medical Staff and are governed by the Medical Staff bylaws, which provide them numerous rights and extensive … While Medical Staff bylaws are designed to protect medical staff, their "numerous rights and extensive
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psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
October 01, 2016 - The extensive customization that is a feature of many EHRs invites clinicians to record the same information … One is the extensive customization of EHRs that leads to problematic nonstandardization.
-
psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - The surgery was technically difficult, due to the patient’s advanced disease and extensive dissection
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psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
February 01, 2012 - After extensive discussions, the family agreed to a DNR [do not resuscitate] order for the patient, but
-
psnet.ahrq.gov/node/33851/psn-pdf
January 01, 2017 - In particular, an extensive body of
research has examined the weekend effect—the purportedly increased