-
psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
October 19, 2022 - SPOTLIGHT CASE
Resuscitation Errors: A Shocking Problem
Citation Text:
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
…
-
psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - SPOTLIGHT CASE
Thin Air
Citation Text:
Gaba DM. Thin Air. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
-
psnet.ahrq.gov/node/848109/psn-pdf
April 26, 2023 - The Danger of 10% Intravenous Calcium Chloride
Extravasation.
April 26, 2023
The Danger of 10% Intravenous Calcium Chloride Extravasation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
The Case
A 52-year-old man with a history of lymphoplasmacytic lymph…
-
psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Elizabeth Gould, NP-C, COR…
-
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…
-
psnet.ahrq.gov/web-mm/confusion-acetaminophen
December 01, 2009 - Confusion With Acetaminophen
Citation Text:
Heubi JE. Confusion With Acetaminophen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
-
psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - clinician reviewers judged misdiagnosis to have occurred in 5% of these children presenting with acute illness
-
psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
March 01, 2014 - , CRE, other MDR GNR)
Tuberculosis
Fungal disease (e.g., aspergillus)
Respiratory illness
-
psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - assigning class 3 or 4 heart failure status on the basis of symptoms reported in a history of present illness
-
psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - , CRE, other MDR GNR)
Tuberculosis
Fungal disease (e.g., aspergillus)
Respiratory illness
-
psnet.ahrq.gov/node/841467/psn-pdf
December 14, 2022 - limitations of medical expertise,7 the patient’s own role in their care,8,9 or the uniqueness of a
patient’s illness
-
psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx
Spotlight
Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm…
-
psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
October 30, 2024 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
Linkedin
C…
-
psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
-
psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the
Senior Clinical Data Analyst at Atrium Health, and Rhonda
Dickman, MSN, RN, CPHQ, the Director of the Tennessee
Hospital Association PSO
January 12, 2022
In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and
Rhonda…
-
psnet.ahrq.gov/node/49666/psn-pdf
October 01, 2012 - CA-MRSA Skin Infections: An Ounce of Prevention is
Worth a Pound of Cure
October 1, 2012
Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet].
2012.
https://psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
Case Objectives
Identify risk f…
-
psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD
August 1, 2012
In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
Editor's note: The topic of patient safety in long-term care facilities has not received the attent…
-
psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
March 24, 2025 - In Conversation With… Rebecca Lawton, PhD
September 1, 2018
Citation Text:
In Conversation With… Rebecca Lawton, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
…
-
psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - Nursing and Patient Safety
Citation Text:
Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XM…
-
psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - Missed CANDOR Implementation Opportunities.
Citation Text:
Schweitzer L. Missed CANDOR Implementation Opportunities.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
Copy Citation
Format:
Google Scholar BibTeX EndN…