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2121. 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…

2122. 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…

2123. First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit | PSNet
      psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
      October 30, 2019 - First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit Jochen Profit, MD, MPH; Annette Scheid, MD; and Erick Ridout, MD | October 30, 2019  Also Read the Conversation View more articles from the same authors. Citation Text: Profit J, …

2124. Health Equity and Maternal Health | PSNet
      psnet.ahrq.gov/perspective/health-equity-and-maternal-health
      October 06, 2021 - Health Equity and Maternal Health October 6, 2021  Also Read the Conversation View more articles from the same authors. Citation Text: Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. Rockville (MD): Agency for Healthcare…

2125. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
      January 01, 2024 - Spotlight Spotlight Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis 1 Source and Credits This presentation is based on the December 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Comment…

2126. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. | PSNet
      psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
      July 02, 2011 - Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. Citation Text: DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…

2127. 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…

2128. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
      January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice Hardeep Singh, MD, MPH | January 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Singh H. Diagnostic Errors: A New Chapter in Patient Safe…

2129. How Does Health Care Simulation Affect Patient Care? | PSNet
      psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
      August 01, 2018 - How Does Health Care Simulation Affect Patient Care? Joseph O. Lopreiato, MD, MPH | August 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Lopreiato JO. How Does Health Care Simulation Affect Patient Care?. PSNet [inter…

2130. 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…

2131. 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…

2132. 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…

2133. 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. …

2134. In Conversation With... Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
      May 14, 2020 - In Conversation With... Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD May 14, 2020  Also Read the Essay Citation Text: In Conversation With.. Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD. PSNet [internet]. 2020.In Conversation With... Joel Willis, DO, PA,…

2135. Telehealth and Patient Safety During the COVID-19 Response | PSNet
      psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
      May 14, 2020 - Telehealth and Patient Safety During the COVID-19 Response May 14, 2020  Also Read the Conversation View more articles from the same authors. Citation Text: Sikka N, Willis JS, Fitall E, et al. Telehealth and Patient Safety During the COVID-19 Response. PSNet [i…

2136. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis | PSNet
      psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
      March 09, 2022 - SPOTLIGHT CASE Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis Citation Text: Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. …

2137. EMS Patient Safety in the Field | PSNet
      psnet.ahrq.gov/perspective/ems-patient-safety-field
      July 28, 2021 - EMS Patient Safety in the Field July 28, 2021  Also Read the Conversation View more articles from the same authors. Citation Text: Augustine JJ, Fitall E, Hall KK, et al. EMS Patient Safety in the Field. PSNet [internet]. Rockville (MD): Agency for Healthcare Re…

2138. 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…

2139. 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…

2140. 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 …