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psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
September 29, 2021 - SPOTLIGHT CASE
CME/MOC
Intraosseous Line Extravasation in a Pediatric Trauma Patient
Citation Text:
Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department o…
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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
September 25, 2024 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected
Citation Text:
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/issue/are-incorrectly-used-drugs-more-frequently-involved-adverse-drug-reactions-prospective-study
March 08, 2017 - Study
Are incorrectly used drugs more frequently involved in adverse drug reactions? A prospective study.
Citation Text:
Jonville-Béra AP, Béra F, Autret-Leca E. Are incorrectly used drugs more frequently involved in adverse drug reactions? A prospective study. Eur J Clin Pharmacol. 20…
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psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
October 01, 2018 - CVC Removal: A Procedure Like Any Other
Citation Text:
Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/846769/psn-pdf
March 29, 2023 - Missed Diagnosis of Addison’s Disease in Adolescent
Presenting with Fatigue.
March 29, 2023
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
The C…
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - A Postpartum Woman with an Erroneous SARS-CoV-2 Test
Citation Text:
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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Forma…
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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - Right Electrocardiogram, Wrong Patient
March 25, 2020
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
The Cases
Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…
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psnet.ahrq.gov/node/49509/psn-pdf
April 01, 2006 - Insert Omission
April 1, 2006
Darney P. Insert Omission. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/insert-omission
The Case
A multiparous woman presented to the gynecology clinic requesting intrauterine contraceptive (IUC)
placement (Figure). She was appropriately counseled on the risks and benefits o…
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psnet.ahrq.gov/node/852700/psn-pdf
August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond
the Pandemic: Creating Total Systems Safety
August 30, 2023
McGaffigan P, Van CM, Mossburg S. In Conversation with.. Patricia McGaffigan about Beyond the
Pandemic: Creating Total Systems Safety . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/con…
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psnet.ahrq.gov/issue/effort-human-factors-performance-and-decision-making
August 31, 2022 - Commentary
Effort in human factors performance and decision making.
Citation Text:
Wickens CD. Effort in human factors performance and decision making. Hum Factors. 2014;56(8):1329-36.
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx
Spotlight
Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See…
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psnet.ahrq.gov/node/33637/psn-pdf
August 01, 2006 - By the time I quit pediatric surgery 20 years later, neonatal mortality was down
to around 2% or 3%.
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psnet.ahrq.gov/issue/understanding-and-improving-everyday-work-healthcare
May 13, 2020 - International Meeting/Conference
Understanding and Improving Everyday Work in Healthcare.
Citation Text:
Clinical Human Factors Group. May 16, 2023, 9:00 AM--12:30 PM (eastern).
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psnet.ahrq.gov/issue/when-does-quality-improvement-count-research-human-subject-protection-and-theories-knowledge
July 10, 2019 - Commentary
When does quality improvement count as research? Human subject protection and theories of knowledge.
Citation Text:
Lynn J. When does quality improvement count as research? Human subject protection and theories of knowledge. Qual Saf Health Care. 2004;13(1):67-70.
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psnet.ahrq.gov/node/49638/psn-pdf
January 01, 2012 - Communication Failure—Who's in Charge?
October 1, 2011
Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge
The Case
A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu…
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
Citation Text:
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - SPOTLIGHT CASE
Don't Dismiss the Dangerous: Obstetric Hemorrhage
Citation Text:
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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…
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psnet.ahrq.gov/web-mm/one-dose-two-errors
September 29, 2017 - One Dose, Two Errors
Citation Text:
Filice GA. One Dose, Two Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/issue/patient-safety-and-systematic-reviews-finding-papers-indexed-medline-embase-and-cinahl
August 04, 2021 - Study
Patient safety and systematic reviews: finding papers indexed in MEDLINE, EMBASE and CINAHL.
Citation Text:
Tanon AA, Champagne F, Contandriopoulos A-P, et al. Patient safety and systematic reviews: finding papers indexed in MEDLINE, EMBASE and CINAHL. Qual Saf Health Care. 2010;…