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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…
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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…
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psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - January 15, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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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. …
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psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
February 21, 2020 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.
Citation Text:
Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
…
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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Communications with the pharmacy and between providers may not happen
consistently due to time constraints
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psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
March 31, 2021 - How could this happen, especially in regard to a life-threatening diagnosis?
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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
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psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - In addition, delayed diagnosis due to access barriers continues to happen
frequently.
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Before this could happen, the patient developed increasing hypoxemia and
respiratory distress, ultimately
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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
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psnet.ahrq.gov/periodic-issue/periodic-issue-305
August 25, 2021 - August 18, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports…
-
psnet.ahrq.gov/periodic-issue/periodic-issue-388
April 26, 2023 - April 26, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
-
psnet.ahrq.gov/periodic-issue/periodic-issue-397
June 28, 2023 - June 28, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
-
psnet.ahrq.gov/periodic-issue/periodic-issue-398
July 31, 2023 - July 5, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, a…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.170_slideshow.ppt
March 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case March 2008
Back Again
Source and Credits
This presentation is based on the March 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jon D. Lurie, MD, MS
Dartmouth Medical School
Editor, AHRQ WebM…
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psnet.ahrq.gov/periodic-issue/periodic-issue-456
September 25, 2024 - September 18, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, repo…
-
psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - The Consequences of Miscommunication Regarding a
Possible Artifact
June 30, 2021
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
Disclosure of Relevant Financial Relationships…
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psnet.ahrq.gov/web-mm/discharging-our-responsibility
January 16, 2019 - Discharging Our Responsibility
Citation Text:
Fonarow GC. Discharging Our Responsibility. 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 X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - Eptifibatide Epilogue
Citation Text:
Churchill WW, Fiumara K. Eptifibatide Epilogue. 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 …