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psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - Interpreting the Patient Safety Literature
Kaveh G. Shojania, MD | June 1, 2005
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Citation Text:
Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/web-mm/chest-tube-complications
September 27, 2023 - Chest Tube Complications
Citation Text:
Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33691/psn-pdf
December 01, 2009 - How to Identify and Manage Problem Behaviors
December 1, 2009
Rosenstein AH, O'Daniel M. How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
Perspective
The 1999 Institute of Medicine report highlighted the need for heal…
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psnet.ahrq.gov/node/49529/psn-pdf
February 01, 2007 - Crossed Coverage
February 1, 2007
Kayser SR. Crossed Coverage. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/crossed-coverage
The Case
A 27-year-old woman with a history of congenital heart disease was admitted for cardiac transplantation
evaluation. She had already undergone multiple surgeries, including…
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - Abnormal Volunteer Results
Citation Text:
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - The Wrong Channel
September 1, 2005
Gosbee JW. The Wrong Channel . PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/wrong-channel
The Case
A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial
dosing started at 50 mL/hour using a multi-channel medication pump…
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psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.
Citation Text:
Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.. PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon
Citation Text:
Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Intraosseous Line Extravasation in a
Pediatric Trauma Patient
Source and Credits
• This presentation is based on the April 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: David Barnes, MD and Joseph Yoon, MD
o…
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psnet.ahrq.gov/node/846171/psn-pdf
July 26, 2022 - Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
March 15, 2023
Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of
Gastric Perforation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/agitated-delirium-contributes…
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psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
March 28, 2023 - We know across the board that care for other health conditions, such as congestive heart failure and
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding
September 1, 2017
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
Case Objectives
Describe risk factors for poor outcome in patients w…
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psnet.ahrq.gov/node/846768/psn-pdf
March 29, 2023 - Endotracheal Tube Fallout in a Patient with Severe
Obesity During Eye Surgery.
March 29, 2023
Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
The Ca…
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psnet.ahrq.gov/node/33743/psn-pdf
December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing
and Treating Delirium in the Intensive Care Unit
December 1, 2012
Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating
Delirium in the Intensive Care Unit. PSNet [internet]. 2012.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
June 01, 2010 - What Do We Know About Emergency Department Safety?
David P. Sklar, MD; Cameron Crandall, MD | June 1, 2010
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Sklar DP, Crandall CS. What Do We Know About Emergency Department Safety…
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psnet.ahrq.gov/node/846975/psn-pdf
March 28, 2023 - We know
across the board that care for other health conditions, such as congestive heart failure and
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psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE
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psnet.ahrq.gov/node/60611/psn-pdf
June 24, 2020 - Direct Oral Anticoagulants are High-Risk Medications with
Potentially Complex Dosing
June 24, 2020
Giannini J, Wong M, Dager W, et al. Direct Oral Anticoagulants are High-Risk Medications with Potentially
Complex Dosing. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk…
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psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md
February 26, 2025 - In Conversation With… Shantanu Nundy, MD
July 1, 2018
Citation Text:
In Conversation With… Shantanu Nundy, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - SPOTLIGHT CASE
Some Patients Can't Wait: Improving Timeliness of Emergency Department Care
Citation Text:
Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…