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psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
September 22, 2010 - 2017
WebM&M Cases
Anchoring Bias With Critical Implications
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psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - Access Procedures in Patients with Kidney Disease
November 27, 2019
Cost implications
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274:29-34. [go to PubMed] 3.
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - There are many implications for further study of patient safety during intrahospital transport of acutely
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psnet.ahrq.gov/node/49783/psn-pdf
February 01, 2017 - How then did it happen, and
what are the implications for the use of checklists and order sets in medicine
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - patients—similar to the six quality aims outlined by the Institute of Medicine—and all of the models have distinct implications … website ) 7, 12 Functions of Primary Care That Meet the Six Aims of Quality Healthcare Ultimate Potential Implications … Primary care access barriers as reported by nonurgent emergency department users: implications for the … think of any examples of changes that you’ve seen in primary care delivery over the years and what the implications
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - Staggered Sensitivity Results
Citation Text:
Guglielmo JB. Staggered Sensitivity 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/web-mm/diuretics-and-electrolyte-abnormalities
February 15, 2017 - Diuretics and Electrolyte Abnormalities
Citation Text:
Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 …
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psnet.ahrq.gov/node/49734/psn-pdf
May 01, 2015 - Departure From Central Line Ritual
May 1, 2015
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/departure-central-line-ritual
The Case
A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…
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psnet.ahrq.gov/node/49731/psn-pdf
April 01, 2015 - Fire in the Hole!—An OR Fire
April 1, 2015
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fire-hole-or-fire
The Case
A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection
for a biopsy-proven adenocarcinom…
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psnet.ahrq.gov/node/49707/psn-pdf
April 01, 2014 - CYP450 Drugs: Expect the Unexpected
April 1, 2014
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
The Case
A 42-year-old man with acquired immunodeficiency syndrome (AIDS) (CD4 count 198), hip dystocia, and
generalized anxiety …
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psnet.ahrq.gov/node/50842/psn-pdf
January 29, 2020 - Patient Identification Errors: A Systems Challenge
January 29, 2020
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
The Cases
The following four events involving five patients all involved…
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - Annual Perspective
Rethinking Root Cause Analysis
Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD | January 1, 2016
View more articles from the same authors.
Citation Text:
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. Rockville (MD): Age…
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psnet.ahrq.gov/web-mm/lethal-vertigo
September 20, 2011 - Lethal Vertigo
Citation Text:
Furman JM. Lethal Vertigo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
July 08, 2022 - SPOTLIGHT CASE
Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy
Citation Text:
Kelly KJ. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcare Resear…
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - EHR Copy and Paste and Patient Safety
Shannon M. Dean, MD | January 1, 2018
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/web-mm/silent-pain-neck
August 19, 2020 - 19, 2020
WebM&M Cases
Anchoring Bias With Critical Implications
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - 2011
Follow-up of markedly elevated serum potassium results in the ambulatory setting: implications
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications
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psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - Although relatively uncommon, RFOs during surgery have significant implications for the patient, including