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4381. The Role of Bar Coding and Smart Pumps in Safety | PSNet
      psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
      September 01, 2008 - Recent tragic events in two leading hospitals underscore prevailing systematic deficiencies in the medication

4382. Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
      January 01, 2023 - inhibition activity on GABA receptors and blocks the excitatory action of glutamate on NMDA receptors, leading

4383. Breakage of a PICC Line | PSNet
      psnet.ahrq.gov/web-mm/breakage-picc-line
      June 21, 2023 - SPOTLIGHT CASE Breakage of a PICC Line Citation Text: Dimov V. Breakage of a PICC Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

4384. The "Customer" Is Always Right | PSNet
      psnet.ahrq.gov/web-mm/customer-always-right
      January 22, 2014 - SPOTLIGHT CASE The "Customer" Is Always Right Citation Text: Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote…

4385. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837659/psn-pdf
      July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging July 8, 2022 Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging The Cases Case #1: A 42-year-old woman admitted with…

4386. Who Nose Where the Airway Is? | PSNet
      psnet.ahrq.gov/web-mm/who-nose-where-airway
      May 01, 2016 - Who Nose Where the Airway Is? Citation Text: Lee CR. Who Nose Where the Airway Is?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

4387. Too Tight Control | PSNet
      psnet.ahrq.gov/web-mm/too-tight-control
      March 20, 2013 - SPOTLIGHT CASE Too Tight Control Citation Text: Rubin HR, Fajtova VT. Too Tight Control. 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…

4388. July Syndrome | PSNet
      psnet.ahrq.gov/web-mm/july-syndrome
      July 01, 2011 - July Syndrome Citation Text: Young JQ. July Syndrome. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS D…

4389. Methicillin-Resistant Staphylococcus aureus | PSNet
      psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
      June 24, 2010 - Methicillin-Resistant Staphylococcus aureus Gary A. Noskin, MD | April 1, 2008  View more articles from the same authors. Citation Text: Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…

4390. The Wrong Shot: Error Disclosure | PSNet
      psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
      May 01, 2011 - SPOTLIGHT CASE The Wrong Shot: Error Disclosure Citation Text: Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Sch…

4391. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49829/psn-pdf
      May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…

4392. Empty Handoff | PSNet
      psnet.ahrq.gov/web-mm/empty-handoff
      August 01, 2017 - Empty Handoff Citation Text: Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

4393. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846563/psn-pdf
      March 21, 2023 - Impact of System Failures on Healthcare Workers March 21, 2023 Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers Introduction The March 2022 conviction of RaDonda Vaught, a former nu…

4394. Complications of Vascular Access Procedures in Patients with Kidney Disease | PSNet
      psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
      November 15, 2023 - Complications of Vascular Access Procedures in Patients with Kidney Disease Citation Text: Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

4395. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49639/psn-pdf
      November 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin…

4396. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74251/psn-pdf
      January 26, 2022 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest January 26, 2022 Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022. https…

4397. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33814/psn-pdf
      September 01, 2016 - In Conversation With… Reed V. Tuckson, MD September 1, 2016 In Conversation With… Reed V. Tuckson, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md Editor's note: Dr. Tuckson is Managing Director of Tuckson Health Connections, LLC, and President of the American Telemed…

4398. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49864/psn-pdf
      June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…

4399. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33718/psn-pdf
      October 01, 2011 - In Conversation With… Paul G. Shekelle, MD, MPH, PhD October 1, 2011 In Conversation With… Paul G. Shekelle, MD, MPH, PhD. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd Editor's note: Dr. Shekelle is director of the Southern California Evidence-Based Practice Cen…

4400. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49528/psn-pdf
      January 01, 2015 - The "Customer" Is Always Right February 1, 2007 Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/customer-always-right Case Objectives Understand the importance of identifying a patient's agenda. Appreciate the factors that contribute to unmet patient expectations. …