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  1. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery | PSNet

    psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
    January 29, 2021 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery Citation Text: Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qual…

  2. Overuse as a Patient Safety Problem | PSNet

    psnet.ahrq.gov/perspective/overuse-patient-safety-problem
    September 01, 2014 - Overuse as a Patient Safety Problem Christopher Moriates, MD | September 1, 2014  Also Read a Conversation View more articles from the same authors. Citation Text: Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. Rockville (MD): Agency for Heal…

  3. A Loss of Trust and a Missed Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
    October 31, 2023 - SPOTLIGHT CASE A Loss of Trust and a Missed Diagnosis Citation Text: Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format:…

  4. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet

    psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - SPOTLIGHT CASE Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Citation Text: Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…

  5. In Conversation With… Rosemary Gibson, MSc | PSNet

    psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
    September 01, 2014 - In Conversation With… Rosemary Gibson, MSc September 1, 2014  Also Read an Essay Citation Text: In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…

  6. Making Healthcare Safer III Report | PSNet

    psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
    March 30, 2020 - Making Healthcare Safer III Report March 30, 2020  Also Read the Conversation View more articles from the same authors. Citation Text: Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. Rockville (MD): Agency for Health…

  7. In Conversation With… Wanda Pratt, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
    November 01, 2017 - In Conversation With… Wanda Pratt, PhD November 1, 2017  Also Read an Essay Citation Text: In Conversation With… Wanda Pratt, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Cop…

  8. Life-Threatening Infant Overdose of Sodium Chloride | PSNet

    psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
    December 23, 2020 - Life-Threatening Infant Overdose of Sodium Chloride Citation Text: Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Form…

  9. Missed Nursing Care: A Key Measure for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
    March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety Jane Ball, PhD, and Peter Griffiths, PhD | March 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient…

  10. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case | PSNet

    psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
    October 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case Citation Text: Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US …

  11. Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
    January 01, 2021 - Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only Spotlight Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism Source and Credits • This presentation is based on the February 2021 AHRQ WebM&M Spotlight Case o See the full article at ht…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850673/psn-pdf
    June 14, 2023 - In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm June 14, 2023 Johnson B. In Conversation with.. Beverley H. Johnson about The Role of Patient's Family In Reducing Harm. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-r…

  13. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning | PSNet

    psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
    January 29, 2021 - SPOTLIGHT CASE A Missed Bowel Perforation - the Importance of Diagnostic Reasoning Citation Text: Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…

  14. The Safety of Medical Devices | PSNet

    psnet.ahrq.gov/perspective/safety-medical-devices
    June 01, 2011 - The Safety of Medical Devices Christopher Nemeth, PhD | June 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…

  15. In Conversation with…David W. Bates, MD, MSc | PSNet

    psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
    May 01, 2018 - In Conversation with…David W. Bates, MD, MSc May 1, 2008  Also Read an Essay Citation Text: In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008…

  16. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. | PSNet

    psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
    October 31, 2023 - SPOTLIGHT CASE Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. Citation Text: Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853902/psn-pdf
    September 27, 2023 - A Missed Bowel Perforation - the Importance of Diagnostic Reasoning September 27, 2023 Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning Disclosure of …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843234/psn-pdf
    January 01, 2013 - Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. February 1, 2023 Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive D…

  19. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression | PSNet

    psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
    May 26, 2021 - SPOTLIGHT CASE Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression Citation Text: Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837913/psn-pdf
    August 31, 2022 - Miscommunication During the Interhospital Transport of a Critically Ill Child August 31, 2022 Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-c…
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