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  1. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
    January 01, 2023 - – Capnography can detect hypoventilation caused by decreased respiratory drive leading to a rise in

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73334/psn-pdf
    August 01, 2024 - psnet.ahrq.gov//#33 https://psnet.ahrq.gov//#34 infusions.31,52 Here, we briefly outline some recent leading

  3. An Inadvertent Bolus of Norepinephrine. | PSNet

    psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
    December 04, 2016 - action to improve the management of multiple IV infusions. 31 , 52 Here, we briefly outline some recent leading

  4. In Conversation with…Thomas J. Nasca, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
    February 01, 2010 - programs, most of which lacked a standardized way to manage this discontinuity in 2003 ( 22 ), are now leading

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850678/psn-pdf
    June 14, 2023 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration June 14, 2023 https://psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults- risk-hospital Summary To address a well-documented hospital adverse outco…

  6. Triage Time Bomb | PSNet

    psnet.ahrq.gov/web-mm/triage-time-bomb
    September 01, 2008 - Triage Time Bomb Citation Text: Washington DL. Triage Time Bomb. 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 7 XML Endnote tagged PubMedId RIS …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840175/psn-pdf
    November 16, 2022 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism. November 16, 2022 Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism The Case A 61-year-old woman presented to …

  8. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital | PSNet

    psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
    May 16, 2022 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital Citation Text: Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…

  9. Transfusion "Slip" | PSNet

    psnet.ahrq.gov/web-mm/transfusion-slip
    June 14, 2011 - Transfusion "Slip" Citation Text: Kaplan HS. Transfusion "Slip". 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 7 XML Endnote tagged PubMedId RIS …

  10. Bloody BP Cuff | PSNet

    psnet.ahrq.gov/web-mm/bloody-bp-cuff
    June 21, 2016 - Bloody BP Cuff Citation Text: Madan AK. Bloody BP Cuff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  11. Don't Use That Port: Insert a PICC | PSNet

    psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
    December 22, 2018 - Don't Use That Port: Insert a PICC Citation Text: Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49794/psn-pdf
    May 01, 2017 - Communication Error in a Closed ICU May 1, 2017 Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/communication-error-closed-icu The Case A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney transplant), co…

  13. The Context Is the Intervention | PSNet

    psnet.ahrq.gov/perspective/context-intervention
    August 05, 2020 - The Context Is the Intervention Dr. John Øvretveit | October 1, 2011  View more articles from the same authors. Citation Text: Øvretveit J. The Context Is the Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …

  14. In Conversation With… Kathleen Sutcliffe, MN, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd
    April 26, 2023 - In Conversation With… Kathleen Sutcliffe, MN, PhD April 1, 2017  Citation Text: In Conversation With… Kathleen Sutcliffe, MN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy C…

  15. The Forgotten Radiographic Read | PSNet

    psnet.ahrq.gov/web-mm/forgotten-radiographic-read
    June 07, 2016 - The Forgotten Radiographic Read Citation Text: Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…

  16. Think Like a Surgeon | PSNet

    psnet.ahrq.gov/web-mm/think-surgeon
    December 04, 2024 - Think Like a Surgeon Citation Text: Cooper Z. Think Like a Surgeon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

  17. Right Place, Right Drug, Wrong Strength | PSNet

    psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
    March 26, 2015 - Right Place, Right Drug, Wrong Strength Citation Text: Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX En…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33691/psn-pdf
    December 01, 2009 - How to Identify and Manage Problem Behaviors December 1, 2009 Rosenstein AH, O'Daniel M. How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors Perspective The 1999 Institute of Medicine report highlighted the need for heal…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49495/psn-pdf
    December 01, 2005 - Low on the Totem Pole December 1, 2005 Wachter R. Low on the Totem Pole. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/low-totem-pole Case Objectives Understand the concept of authority gradient List steps that can be taken to increase communication across an authority gradient Consider the current cultu…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49417/psn-pdf
    October 01, 2003 - Lost in the Black Hole October 1, 2003 Wachter R. Lost in the Black Hole. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lost-black-hole The Case A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis. She had a remote history of gonorrhea, no environmental exposu…
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