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5181. 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…

5182. 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…

5183. 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. …

5184. 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.…

5185. 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…

5186. 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…

5187. 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 …

5188. 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…

5189. 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…

5190. 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…

5191. The "Customer" Is Always Right | PSNet
      psnet.ahrq.gov/web-mm/customer-always-right
      January 22, 2014 - SPOTLIGHT CASE The "Customer" Is Always Right Citation Text: Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote…

5192. 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…

5193. 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…

5194. Mother's Milk, but Whose Mother? | PSNet
      psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
      November 15, 2023 - Mother's Milk, but Whose Mother? Citation Text: Dougherty D. Mother's Milk, but Whose Mother?. 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 XM…

5195. Doctor, Don't Treat Thyself | PSNet
      psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
      August 21, 2024 - Doctor, Don't Treat Thyself Citation Text: Rosvold EO. Doctor, Don't Treat Thyself. 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 t…

5196. Inadequate Preanesthetic Evaluation, Airway Trouble | PSNet
      psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
      November 01, 2023 - Inadequate Preanesthetic Evaluation, Airway Trouble Citation Text: Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar …

5197. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72811/psn-pdf
      September 01, 2022 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors Originally published on March 3, 2021 Last updated on March 16, 2021 https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during- initial-treatment Summar…

5198. Buprenorphine and the Medically Ill Patient | PSNet
      psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
      August 20, 2018 - Buprenorphine and the Medically Ill Patient Citation Text: McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX E…

5199. Empty Handoff | PSNet
      psnet.ahrq.gov/web-mm/empty-handoff
      August 01, 2017 - Empty Handoff Citation Text: Goldman A, Catchpole K. Empty Handoff. 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 PubMedId R…

5200. Who Nose Where the Airway Is? | PSNet
      psnet.ahrq.gov/web-mm/who-nose-where-airway
      May 01, 2016 - Who Nose Where the Airway Is? Citation Text: Lee CR. Who Nose Where the Airway Is?. 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 Endnote t…