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21. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. | PSNet
    psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
    January 29, 2021 - Qual Saf Health Care . 2005;14(3):e3. [ Free full text ] Gavel G, Walker RWM. … Cureus . 2020;12(5):e8196. [ Free full text ] Mokhtar AM, Badawy AA. … Drug Des Devel Ther . 2021;15:3893-3901. [ Free full text ] Larson CP Jr. … Anesthesiology . 1998 Nov;89(5):1293-4. . [ Free full text ] Johnstone RE. … Eur J Anaesthesiol . 201;35(1):49-59. [ Free full text ] Bohringer C, Liu H.

22. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia. | PSNet
    psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
    January 29, 2021 - Sleep . 2019;42(5):zsz041. [ Free full text ] Fletcher KE, Reed DA, Arora VM. … Ann Surg . 2017;265(2):340-346. [ Free full text ] Sinha A, Singh A, Tewari A. … Anesth Analg . 2019;129(5):1199-1201. [ Free full text ] Morriss WW, Enright AC. … Saf Health Work . 2019;10(4):512-517. [ Free full text ] Park S, Lee W, Lee JH. … Hypertension . 1999;33(3):869-873. [ Free full text ] Enriquez A, Frankel DS.

23. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
    January 01, 2024 - [Free full text] 3. … [Free full text] 6. Matics TJ, Sanchez-Pinto LN. … [Free full text] 18. Su-Ting T. Li, Daniel J. … [Free full text] 20. Croskerry P. … [Free full text] 22. Balakrishnan K, Arjmand EM.

24. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
    January 01, 2024 - [Free full text] 2. Shahian DM, He X, Jacobs JP, et al. … [Free full text] 17.Schwarz ME, Broome IJ. … [Free full text] 21.Batra AS, Balaji S. … [Free full text] 23.Bhat C, Yadav K, Rosenberg H. … [Free full text] 24.Xing L, Wu S, Zhong X, et al.

25. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - [Free full text] 5. Wei M, Ho E, Hegde P. … [Free full text] 14. Boeykens K, Duysburgh I. … [Free full text] 18. Turan UF, Katar MK. … [Free full text] 32. Pratt J, Green S. … [Free full text] 39. Ong MS, Coiera E.

26. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. | PSNet
    psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
    January 29, 2021 - Age (Dordr) . 2016;38(1):23.[ Free full text ] Ho JY. … Heart Fail Rev . 2022;27(5):1807-1817. [ Free full text ] Bohringer, C. … Accessed March 24, 2023. [ Free full text ] Liew WJ, Negar A, Singh PA. … Transl Perioper Pain Med . 2020;7(1):152-157. [ Free full text ] Palte HD. … Anesth Analg . 2016;122(5):1439-1443. [ Free full text ] Cavallone LF, Vannucci A.

27. Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
    January 01, 2023 - [Free full text] 2. Nofal E, Farag F, Nofal A, et al. … [Free full text] 5. Atalay H, Solak Y, Biyik Z, et al. … [Free full text] 8. Miller A, Price G. … [Free full text] 13. Corona AG, Garcia P, Gelfand SL. … [Free full text]

28. Integrating adverse event reporting into a free-text mobile application used in daily workflow increases adverse event reporting by physicians. | PSNet
    psnet.ahrq.gov/issue/integrating-adverse-event-reporting-free-text-mobile-application-used-daily-workflow
    March 15, 2023 - Study Integrating adverse event reporting into a free-text mobile application used … Integrating adverse event reporting into a free-text mobile application used in daily workflow increases … PubMed citation Full free text Save Save to your library Print Share … Integrating adverse event reporting into a free-text mobile application used in daily workflow increases … Same Author(s) Safety risks and workflow implications associated with nursing-related free-text

29. COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care | PSNet
    psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care
    February 24, 2022 - J Infect . 2020;81(2):e145-e147. [ Free full text ] Zhu J, Guo J, Xu Y, et al. … J Infect . 2020;81(3):e48-e50. [ Free full text ] Peng X, Xu X, Li Y, et al. … J Occup Health . 2018;60(2):111-125. [ Free full text ] Coulthard P. … N Engl J Med . 2020;382(10):970-971. [ Free full text ] Wu Z, McGoogan JM. … Accessed November 2021. [ Free full text] ADA policy on teledentistry.

30. Maternal Safety | PSNet
    psnet.ahrq.gov/primer/maternal-safety
    January 10, 2024 - NCHS Data Brief . 2023;(477):1-8. [ Free full text ] Births – Method of Delivery. … MMWR Morb Mortal Wkly Rep . 2019;68(35):762-765. [ Free full text ] Howell EA. … Am J Obstet Gynecol . 2016;215(6):795.e1-795.e14. [ Free full text ] Lyndon A. … Accessed January 24, 2024. [ Free full text ]] Cilenti D, Tissue MM, deRosset L. … Matern Child Health J . 2022;26(Suppl 1):1-2. [ Free full text ] Perinatal Equity.

31. Events Calendar | PSNet
    psnet.ahrq.gov/training-catalog/events-calendar
    Medicare and Medicaid Services Quality Improvement Organizations Event Description: Free … Event Location: Online Date: Various Dates Event Fee: Free CE or CME Offered?

32. Do Not Miss Sepsis Needles in Viral Haystacks! | PSNet
    psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
    April 01, 2021 - JAMA . 2016;315(8):775-787. [ Free full text ] Matics TJ, Sanchez-Pinto LN. … Arch Dis Child . 2007;92(5):394-398. [ Free full text ] Li ST, Tancredi DJ. … Am J Med . 2008;121(5 suppl):S2-23. [ Free full text ] Croskerry P. … Hosp Pediatr . 2021;11(3):215-222. [ Free full text ] Mamede S, Schmidt HG. … BMJ Qual Saf . 2016;25(10):808-820. [ Free full text ] Croskerry P.

33. Cranky comments: detecting clinical decision support malfunctions through free-text override reasons. | PSNet
    psnet.ahrq.gov/issue/cranky-comments-detecting-clinical-decision-support-malfunctions-through-free-text-override
    April 13, 2016 - Study Cranky comments: detecting clinical decision support malfunctions through free-text … Cranky comments: detecting clinical decision support malfunctions through free-text override reasons. … PubMed citation Free full text Related news article Save Save to your library … Cranky comments: detecting clinical decision support malfunctions through free-text override reasons. … July 11, 2012 Communication failure: analysis of prescribers' use of an internal free-text

34. Post-Acute Transitional Services: Safety in Home-Based Care Programs | PSNet
    psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
    February 24, 2022 - Drug Saf . 2020 Jun;43(6):517-37. [ Free full text] Boling PA. … J Gen Intern Med . 2014;29(2):283-289. [ Free full text ] Bernheim SM, Ross JS. … Health Serv Res . 2017;52(2):879-894. [ Free full text ] Yang, J. … JAMA Intern Med . 2019;179(5):617-23. [ Free full text ] Durning MV. … J Am Geriatr Soc . 2019;67(9):1859-1865. [ Free full text ] Ree E, Wiig S.

35. A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion. | PSNet
    psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
    June 14, 2023 - Gen Hosp Psychiatry . 2012;34(3):290-298. [ Free full text ] Prin M, Wunsch H. … J Addict Med . 2020;14(3S Suppl 1):1-72. [ Free full text ] Mayo-Smith MF. … Drugs . 2015;75(4):353-365. [ Free full text ] Perry EC. … Alcohol Res . 2015;37(2):177-184. [ Free full text ] Lyons PG, Kollef MH. … Alcohol Clin Exp Res . 2013;37(9):1536-1543. [ Free full text ] Day E, Daly C.

36. Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
    January 01, 2023 - [Free full text] 6. Smiley RM, Friedman AM. … [Free full text] 9. … [Free full text] 17. Guglielminotti J, Li G. … [Free full text]. 27. Dillon S. … [Free full text]

37. Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
    January 01, 2023 - [Free full text] 2. Liu J, Li Z, Liu S, Wang X, Xu Z, Tang P. … [Free full text] 4. Aspinall S, Oweis D, Chadwick D. … [Free full text] 6. Yee TJ, Swong K, Park P. … [Free full text] 7. Campbell MJ, McCoy KL, Shen WT, et al. … [Free full text] 14. Fan C, Zhou X, Su G, et al.

38. Failure to adhere to dietary restrictions leading to complications and poor follow-up. | PSNet
    psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
    September 27, 2023 - There was no free air or other signs of perforation. … Front Pediatr . 2022;10:848092. [ Free full text ] Dörterler ME. … [Free full text ] Vitagliano JA, Jhe G, Milliren CE, et al. … Int J Legal Med . 2020;134(6):2121-2132. [ Free full text ] Nason KS. … [Free full text ] .  

39. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet
    psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - Am J Cardiol . 2021;140:154-156. [ Free full text ] Bõhm A, Székely A, Préda I. … JA Clin Rep . 2016;2(1):3. [ Free full text ] Liu Y, Zhang L, Wang S, et al. … Crit Care . 2016;20(1):298. [ Free full text ] Schwarz ME, Broome IJ. … J Am Coll Cardiol . 2019;73(8):964-976. [ Free full text ] Batra AS, Balaji S. … CJEM . 2023;25(4):297-298. [ Free full text ] Xing L, Wu S, Zhong X, et al.

40. Airway Obstruction during Anterior Cervical Spine Surgery | PSNet
    psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
    January 29, 2021 - Transl Perioper Pain Med . 2019;6(1):5-16. [ Free full text ] Seex KA. … J Clin Anesth . 2013;25(1):66-72. [ Free full text ] Lee CP, Yip YY. … Front Surg . 2017;4:8. [ Free full text ] Wong P, Wong J, Mok MU. … Biomed Res Int . 2014;2014:762053. [ Free full text ] Runciman WB, Merry AF. … Indian J Anaesth . 2019;63(11):908-914. [ Free full text ] Lei C, Palm K.