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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx
Spotlight
Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/…
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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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psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
May 01, 2018 - SPOTLIGHT CASE
Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency
Citation Text:
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
March 24, 2019 - Hypoxemia after Emergency Intubation
Citation Text:
Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
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May 29, 2024
View more articles from the same authors.
Inno…
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psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
July 21, 2020 - SPOTLIGHT CASE
Anemia and Delayed Colon Cancer Diagnosis
Citation Text:
Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - Delayed Breast Cancer Diagnosis: A False Sense of Security.
Citation Text:
Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/33686/psn-pdf
August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS
August 1, 2009
In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
Editor's note: Steven Spear, DBA, MS, MS, is Senior Lecturer at Massachusetts Institute of Tech…
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psnet.ahrq.gov/node/33752/psn-pdf
August 01, 2013 - In Conversation With… J. Bryan Sexton, PhD, MA
August 1, 2013
In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
Editor's note: J. Bryan Sexton, PhD, is associate professor and director of the Patient Safety Center for
the D…
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psnet.ahrq.gov/node/49553/psn-pdf
January 01, 2008 - Contaminated or Not? Guidelines for Interpretation of
Positive Blood Cultures
January 1, 2008
Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
The…
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psnet.ahrq.gov/node/49657/psn-pdf
July 01, 2012 - Not-So-Therapeutic Tap
July 1, 2012
Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
Case Objectives
Describe current issues with training clinicians to perform procedures.
Understand how simulation can be used to ensure trainees are competent in proc…
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psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
April 26, 2023 - Annual Perspective
Technology as a Tool for Improving Patient Safety
A Jay Holmgren, Susan McBride,Bryan Gale, Sarah Mossburg
| March 29, 2023
View more articles from the same authors.
Citation Text:
Holmgren AJ, McBride S, Gale B, et al. Technology as a …
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psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
November 16, 2022 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures
Citation Text:
Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - Airway Obstruction during Anterior Cervical Spine Surgery
Citation Text:
Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - SPOTLIGHT CASE
Isolated Clot, Real Error
Citation Text:
Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/866618/psn-pdf
December 31, 2024 - A Fatal Twist in Pseudohyperkalemia
December 31, 2024
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council
for C…
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - SPOTLIGHT CASE
The Perils of Cross Coverage
Citation Text:
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
January 29, 2021 - An Incomplete Anesthesia History Leads to Adverse Outcomes
Citation Text:
Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/867357/psn-pdf
December 18, 2024 - Hypoxemia after Emergency Intubation
December 18, 2024
Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
The Case
A 19-month-old child was brought to the emergency department (ED) via ambulance after drowning in a
p…
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psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
June 15, 2022 - SPOTLIGHT CASE
Anchoring Bias With Critical Implications
Citation Text:
Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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