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4721. Rediscovering the Power of the Surgical M&M Conference: The M M Matrix | PSNet
      psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
      September 01, 2007 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads

4722. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-04/final_april-spotlight-implicit_biases_04.02.2020.pdf
      January 01, 2020 - Spotlight Spotlight Implicit Biases, Interprofessional Communication, and Power Dynamics Source and Credits • This presentation is based on the April 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Erin Stephany Sanchez, MD, Melody Tran- Reina, MD, Kupi…

4723. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
      January 01, 2022 - Spotlight Spotlight Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by K…

4724. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849661/psn-pdf
      June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery June 28, 2023 Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023. https://psnet.ahrq.gov/web…

4725. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49483/psn-pdf
      June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…

4726. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838221/psn-pdf
      September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH September 28, 2022 In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph Editor’s Note: Freya Spielberg, MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social enterp…

4727. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60268/psn-pdf
      April 29, 2020 - Complications of ECMO During Transport April 29, 2020 Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport The Case A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with acute on chro…

4728. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49564/psn-pdf
      July 01, 2008 - Dependence vs. Pain July 1, 2008 Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dependence-vs-pain Case Objectives Define opioid dependence and opioid withdrawal syndrome. Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid Withdra…

4729. Promising Areas for Patient Safety Research | PSNet
      psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
      November 02, 2016 - Promising Areas for Patient Safety Research P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH | December 1, 2003  View more articles from the same authors. Citation Text: Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. …

4730. Equity in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/equity-patient-safety
      September 24, 2024 - Annual Perspective Equity in Patient Safety Angela D. Thomas, DrPH, MPH, MBA; Merton Lee, PhD, PharmD; Sarah Mossburg, RN, PhD | March 27, 2024  View more articles from the same authors. Citation Text: Thomas A, Lee M, Mossburg S. Equity in Patient Safety. …

4731. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865466/psn-pdf
      March 27, 2024 - Equity in Patient Safety March 27, 2024 Thomas A, Lee M, Mossburg S. Equity in Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/equity-patient-safety Introduction Safety and equity are among the central components that determine quality of care, according to nonprofit advisory agencies l…

4732. In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
      February 26, 2025 - In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD April 1, 2019  Citation Text: In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

4733. In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
      August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD August 1, 2016  Also Read an Essay Citation Text: In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Heal…

4734. In Conversation With… Leah Binder, MA, MGA | PSNet
      psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga
      February 26, 2025 - In Conversation With… Leah Binder, MA, MGA April 1, 2014  Citation Text: In Conversation With… Leah Binder, MA, MGA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Fo…

4735. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72911/psn-pdf
      March 15, 2021 - The Impact of Communication on Medication Errors March 15, 2021 Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors The Case   A 93-year-old man with a history of chronic systolic heart failure…

4736. Monitoring Fetal Health | PSNet
      psnet.ahrq.gov/web-mm/monitoring-fetal-health
      September 08, 2010 - SPOTLIGHT CASE Monitoring Fetal Health Citation Text: Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNot…

4737. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843051/psn-pdf
      February 01, 2023 - Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. February 1, 2023 Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-…

4738. Getting to the Root of the Matter | PSNet
      psnet.ahrq.gov/web-mm/getting-root-matter
      September 01, 2005 - SPOTLIGHT CASE Getting to the Root of the Matter Citation Text: Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Schola…

4739. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850361/psn-pdf
      June 14, 2023 - Critical Echocardiogram Result Lost to Follow-up June 14, 2023 Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow The Case A 63-year-old man with history of stroke, systolic heart failure, and ventric…

4740. Aviation Safety Methods: Quickly Adopted but Questions Remain | PSNet
      psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
      January 01, 2006 - In most cases, the application of these methods leads to questions about whether and how they improve