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4961. Central Line Clot | PSNet
      psnet.ahrq.gov/web-mm/central-line-clot
      August 04, 2021 - SPOTLIGHT CASE Central Line Clot Citation Text: Randolph AG. Central Line Clot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…

4962. The Different Count Contributions to Retention (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
      January 01, 2024 - The Different Count Contributions to Retention Differential Count Contributions in Retained Surgical Sponge Cases: Examination of Administrative Penalty Cases from the California Department of Public Health (CDPH), Health and Safety Code Section 1280.1 Enforcement Reports from 2007-2014 A NoThing Left Behin…

4963. Continuing Education | PSNet
      psnet.ahrq.gov/continuing-education
      February 26, 2025 - Continuing Education What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…

4964. Innovations | PSNet
      psnet.ahrq.gov/innovations
      February 26, 2025 - Innovations The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …

4965. Standard Deviations | PSNet
      psnet.ahrq.gov/web-mm/standard-deviations
      January 01, 2006 - SPOTLIGHT CASE Standard Deviations Citation Text: Sabin JE. Standard Deviations. 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 E…

4966. Undetected Foreign Object | PSNet
      psnet.ahrq.gov/web-mm/undetected-foreign-object
      April 24, 2018 - Undetected Foreign Object Citation Text: Cima RR. Undetected Foreign Object. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…

4967. Complications of Vascular Access Procedures in Patients with Kidney Disease | PSNet
      psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
      November 15, 2023 - Complications of Vascular Access Procedures in Patients with Kidney Disease Citation Text: Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

4968. In Conversation With... James P. Bagian, MD, PE | PSNet
      psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
      February 26, 2025 - In Conversation With... James P. Bagian, MD, PE December 1, 2016  Citation Text: In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016.In Conversation With... James P. Bagian, MD, PE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research a…

4969. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
      January 01, 2024 - Spotlight Spotlight A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis 1 Source and Credits This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Garth Utter, MD, MSc, FACS…

4970. Long-term Care and Patient Safety | PSNet
      psnet.ahrq.gov/primer/long-term-care-and-patient-safety
      February 24, 2022 - Long-term Care and Patient Safety Citation Text: Bakerjian D. Long-term Care and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

4971. Treatment Challenges After Discharge | PSNet
      psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
      January 03, 2017 - SPOTLIGHT CASE Treatment Challenges After Discharge Citation Text: Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar Bib…

4972. It's Sarah, Not Stephen! | PSNet
      psnet.ahrq.gov/web-mm/its-sarah-not-stephen
      January 01, 2015 - SPOTLIGHT CASE It's Sarah, Not Stephen! Citation Text: Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

4973. Slow Down: Right Drug, Wrong Formulation | PSNet
      psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
      October 13, 2018 - Slow Down: Right Drug, Wrong Formulation Citation Text: Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndN…

4974. Medication Administration Errors | PSNet
      psnet.ahrq.gov/primer/medication-administration-errors
      December 15, 2024 - Medication Administration Errors Citation Text: MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X…

4975. Watch the Warfarin! | PSNet
      psnet.ahrq.gov/web-mm/watch-warfarin
      December 01, 2013 - SPOTLIGHT CASE Watch the Warfarin! Citation Text: Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…

4976. Tacit Handover, Overt Mishap | PSNet
      psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
      August 01, 2006 - Tacit Handover, Overt Mishap Citation Text: Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

4977. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose | PSNet
      psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
      March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose Citation Text: Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

4978. 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 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. Citation Text: Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…

4979. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists | PSNet
      psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
      February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists Citation Text: Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…

4980. Autopsy Revelation | PSNet
      psnet.ahrq.gov/web-mm/autopsy-revelation
      December 01, 2007 - Autopsy Revelation Citation Text: Shojania KG. Autopsy Revelation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…