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4941. Point-of-care Mixup: 1 Shot Turns Into 3 | PSNet
      psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
      February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3 Citation Text: Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. 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…

4942. Critical Opportunity Lost | PSNet
      psnet.ahrq.gov/web-mm/critical-opportunity-lost
      February 17, 2017 - Critical Opportunity Lost Citation Text: Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

4943. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860049/psn-pdf
      January 04, 2024 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. January 4, 2024 Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient The Case A 9…

4944. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33673/psn-pdf
      September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety September 1, 2008 Rothschild JM, Keohane C. The Role of Bar Coding and Smart Pumps in Safety. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety Perspective Medication safety in hospitals depends on the successful execu…

4945. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841567/psn-pdf
      December 14, 2022 - Measuring Patient Safety December 14, 2022 Schreiber M, Van C, Mossburg SE. Measuring Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/measuring-patient-safety Following the landmark report To Err is Human: Building a Safer Health System, developed by the Institute of Medicine in 1999, pa…

4946. Project Nurture Engages Pregnant People with Substance Use Disorder, Improves Maternal and Infant Outcomes. | PSNet
      psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-improves-maternal-and
      September 23, 2024 - Project Nurture Engages Pregnant People with Substance Use Disorder, Improves Maternal and Infant Outcomes. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 11, 2021 Innovation …

4947. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment | PSNet
      psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
      June 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment Citation Text: Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …

4948. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33699/psn-pdf
      August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers August 1, 2010 Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers Perspective Academic medical…

4949. Patient Safety in the Physician Office Setting | PSNet
      psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
      November 04, 2015 - Patient Safety in the Physician Office Setting Nancy C. Elder, MD, MSPH | May 1, 2006  View more articles from the same authors. Citation Text: Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…

4950. Too Hot For Comfort | PSNet
      psnet.ahrq.gov/web-mm/too-hot-comfort
      May 19, 2015 - Too Hot For Comfort Citation Text: Cleland H, Wasiak J. Too Hot For Comfort. 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 X3 XML EndNote 7 XML Endnote tagged P…

4951. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73335/psn-pdf
      May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …

4952. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865658/psn-pdf
      April 24, 2024 - Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents? April 24, 2024 Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents? PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/managing-care-challenges-group-…

4953. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49459/psn-pdf
      September 01, 2004 - Caution, Interrupted September 1, 2004 Wears RL. Caution, Interrupted. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/caution-interrupted The Case A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and neutropenia presented to the emergency department (ED) with …

4954. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.368_slideshow.ppt
      February 01, 2016 - PowerPoint Presentation Spotlight Robotic Surgery: Risks vs. Rewards 1 Source and Credits This presentation is based on the February 2016 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Tara Kirkpatrick, MD, and Chad LaGrange, MD, Univer…

4955. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
      January 01, 2022 - Spotlight Spotlight Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis Source and Credits • This presentation is based on the November 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: Narath Carlile MD MPH,…

4956. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49736/psn-pdf
      June 01, 2015 - Inflicting Confusion June 1, 2015 Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/inflicting-confusion The Case A 26-year-old man with recently diagnosed Crohn disease presented to the emergency department with acute-onset abdominal pain, nausea, vomiting, an…

4957. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49604/psn-pdf
      June 01, 2010 - Tacit Handover, Overt Mishap June 1, 2010 Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap The Case A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdo…

4958. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49674/psn-pdf
      December 01, 2012 - Preventing PICC Complications: Whose Line Is It? December 1, 2012 Moureau N. Preventing PICC Complications: Whose Line Is It? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it The Case A 55-year-old woman with myasthenia gravis, hypertension, and hypothyroidism prese…

4959. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49592/psn-pdf
      October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…

4960. Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
      January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx Spotlight Premature Closure: Was it Just Syncope? Source and Credits • This presentation is based on the November 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit i…