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3421. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism | PSNet
      psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
      December 31, 2024 - SPOTLIGHT CASE Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism Citation Text: McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…

3422. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome | PSNet
      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…

3423. Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula | PSNet
      psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
      February 01, 2019 - Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula Jed D. Gonzalo, MD, MSc, and Mamta K. Singh, MD, MSc | February 1, 2019  Also Read a Conversation View more articles from the same authors. Citati…

3424. In Conversation With… Ashish K. Jha, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
      May 01, 2013 - In Conversation With… Ashish K. Jha, MD, MPH May 1, 2013  Also Read an Essay Citation Text: In Conversation With… Ashish K. Jha, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013…

3425. The Ongoing Journey to Prevent Patient Falls | PSNet
      psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
      December 18, 2024 - The Ongoing Journey to Prevent Patient Falls Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD | December 18, 2024  Also Read the Conversation View more articles from the same authors. Citation Text: Dykes PC, Sousane Z, Mossb…

3426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73334/psn-pdf
      August 01, 2024 - An Inadvertent Bolus of Norepinephrine. May 26, 2021 Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counc…

3427. What Have We Learned About Safe Inpatient Handovers? | PSNet
      psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
      March 01, 2011 - What Have We Learned About Safe Inpatient Handovers? Sunil Kripalani, MD, MSc | March 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Kripalani S. What Have We Learned About Safe Inpatient Handovers?. PSNet [internet]. …

3428. Strengthening the Business Case for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
      May 01, 2013 - Strengthening the Business Case for Patient Safety Peter K. Lindenauer, MD, MSc | May 1, 2013  Also Read a Conversation View more articles from the same authors. Citation Text: Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. …

3429. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
      psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
      September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement Carole Stockmeier, MHA, BS, Eric Thomas, MD, MPH, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD | September 24, 2024  Also Read the Conversations In Conversation with Ca…

3430. Can Research Help Us Improve the Medical Liability System? | PSNet
      psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
      March 01, 2012 - Can Research Help Us Improve the Medical Liability System? Allen Kachalia, MD, JD | March 1, 2012  Also Read a Conversation View more articles from the same authors. Citation Text: Kachalia A. Can Research Help Us Improve the Medical Liability System?. PSNet [in…

3431. In Conversation With… Richard C. Boothman, JD | PSNet
      psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
      March 01, 2012 - In Conversation With… Richard C. Boothman, JD March 1, 2012  Also Read an Essay Citation Text: In Conversation With… Richard C. Boothman, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

3432. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit | PSNet
      psnet.ahrq.gov/perspective/quality-and-safety-challenges-critical-care-preventing-and-treating-delirium-intensive
      December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit Eduard E. Vasilevskis, MD; E. Wesley Ely, MD, MPH; Robert S. Dittus, MD, MPH | December 1, 2012  Also Read a Conversation View more articles from the same authors. …

3433. An Inadvertent Bolus of Norepinephrine. | PSNet
      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…

3434. In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls | PSNet
      psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
      December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD | December 18, 2024  Also Read the Essay View more articles from the same authors. Citation…

3435. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet
      psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
      January 23, 2017 - SPOTLIGHT CASE CME/MOC The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. Citation Text: Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Depart…

3436. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
      January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx Spotlight The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department Source and Credits • This presentation is based on the April 2023 AH…

3437. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
      May 01, 2012 - The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety Paul J. Sharek, MD, MPH | May 1, 2012  Also Read a Conversation View more articles from the same authors. Citation Text: Sharek PJ. The Emergence of the Trigger Tool as the …

3438. In Conversation With…David C. Classen, MD, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
      May 01, 2012 - In Conversation With…David C. Classen, MD, MS May 1, 2012  Also Read an Essay Citation Text: In Conversation With…David C. Classen, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…

3439. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848108/psn-pdf
      April 26, 2023 - The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. April 26, 2023 Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/do…

3440. In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances | PSNet
      psnet.ahrq.gov/perspective/conversation-elizabeth-salisbury-afshar-about-harm-reduction-strategies-improve-safety
      October 30, 2024 - In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd | October 30, 2024  Also Read the Essay View more articles from the same auth…