-
psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Before this could happen, the patient developed increasing hypoxemia and
respiratory distress, ultimately
-
psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - In addition, delayed diagnosis due to access barriers continues to happen
frequently.
-
psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - are in place exceeds the permissible ischemia time for the tissue under tourniquet control, as may happen
-
psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - standard preoperative huddle and pre-incision
checklist likely contributed to this near miss, which may happen
-
psnet.ahrq.gov/web-mm/infused-not-ingested
February 01, 2017 - Infused, Not Ingested
Citation Text:
Foley M. Infused, Not Ingested. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
-
psnet.ahrq.gov/node/49544/psn-pdf
September 01, 2007 - Discharging Our Responsibility
September 1, 2007
Fonarow GC. Discharging Our Responsibility. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/discharging-our-responsibility
The Case
A 75-year-old man with a history of hypertension, coronary artery disease, and congestive heart failure
(CHF) presented to the …
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfer Troubles
1
2
Source and Credits
This presentation is based on the June 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…
-
psnet.ahrq.gov/node/49627/psn-pdf
June 01, 2011 - The ECG Is Not Normal
June 1, 2011
Zuger A. The ECG Is Not Normal. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/ecg-not-normal
Case Objectives
State how frequently physicians care for family or relatives.
Describe the risks associated with caring for family members or relatives.
Appreciate some of the s…
-
psnet.ahrq.gov/node/49594/psn-pdf
December 01, 2009 - Standard Deviations
December 1, 2009
Sabin JE. Standard Deviations. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/standard-deviations
Case Objectives
Understand the safety risks associated with patients being discharged against medical advice
(AMA).
Recognize safety risks associated with being part of a …
-
psnet.ahrq.gov/node/49789/psn-pdf
April 01, 2017 - Engaging Seriously Ill Older Patients in Advance Care
Planning
April 1, 2017
Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
Case Objectives
Define advance care planning an…
-
psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - The Case of Mistaken Intubation
June 1, 2016
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/case-mistaken-intubation
Case Objectives
Appreciate that most older adults and many younger chronically ill patients have discussed or
documented their preferences for l…
-
psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
December 01, 2005 - An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up
Robert M. Wachter, MD | June 1, 2012
View more articles from the same authors.
Citation Text:
Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. …
-
psnet.ahrq.gov/web-mm/case-patient-flow-management
February 23, 2019 - The Case for Patient Flow Management
Citation Text:
Litvak E, Bernheim SA. The Case for Patient Flow Management. 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 X…
-
psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - A Mistaken Dose of Naloxone
Citation Text:
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
-
psnet.ahrq.gov/node/865374/psn-pdf
March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and
Challenges
March 27, 2024
Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
Introducti…
-
psnet.ahrq.gov/web-mm/after-visit-confusion
August 21, 2007 - After-Visit Confusion
Citation Text:
Ventres W. After-Visit Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
-
psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - One Bronchoscopy, Two Errors
Citation Text:
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
-
psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. 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 tagged PubMedI…
-
psnet.ahrq.gov/node/841469/psn-pdf
December 14, 2022 - Strongyloides: A Hidden Traveler and Potentially Lethal
Missed Diagnosis.
December 14, 2022
Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed
Diagnosis. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-mi…
-
psnet.ahrq.gov/web-mm/preventable-rash
October 01, 2012 - Preventable Rash
Citation Text:
McLean C. Preventable Rash. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…