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5021. 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…

5022. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33820/psn-pdf
      December 01, 2016 - In Conversation With... James P. Bagian, MD, PE December 1, 2016 In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe Editor's note: Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the Uni…

5023. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73998/psn-pdf
      October 27, 2021 - The Hidden Danger of Unseen Intravenous Catheters October 27, 2021 Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters The Case A 6-week-old infant underwent a craniotomy and excision of abnormal bra…

5024. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49706/psn-pdf
      January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue April 1, 2014 Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue The Case A 24-year-old wom…

5025. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838972/psn-pdf
      October 27, 2022 - The Unhappy Patient Leaves Against Medical Advice. October 27, 2022 Nichols A. The Unhappy Patient Leaves Against Medical Advice. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice The Case A 61-year-old woman was placed on bedrest following major surgery. Her posto…

5026. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
      August 01, 2014 - PowerPoint Presentation Spotlight Pitfalls in Diagnosing Necrotizing Fasciitis This presentation is based on the July/August 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Terence Goh, MBBS, Department of Plastic Surgery, Singapore General Hos…

5027. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49696/psn-pdf
      December 01, 2013 - New Oral Anticoagulants December 1, 2013 Fang MC. New Oral Anticoagulants. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/new-oral-anticoagulants Case Objectives Review properties of newer target-specific oral anticoagulants (TSOACs) such as dabigatran, rivaroxaban, and apixaban. State key perioperative c…

5028. 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 …

5029. 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…

5030. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49554/psn-pdf
      January 01, 2008 - Chemotherapy Extravasation January 1, 2008 Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/chemotherapy-extravasation The Case A 73-year-old woman with no past medical history was diagnosed with stage IIIA breast cancer. She and her oncologist decided to begin sys…

5031. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49662/psn-pdf
      August 01, 2012 - Wrong Turn through Colon: Misplaced PEG August 1, 2012 Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg The Case An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…

5032. One Dose, Fifty Pills | PSNet
      psnet.ahrq.gov/web-mm/one-dose-fifty-pills
      January 13, 2021 - One Dose, Fifty Pills Citation Text: Smith L. One Dose, Fifty Pills . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

5033. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836939/psn-pdf
      April 27, 2022 - A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic April 27, 2022 https://psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19- pandemic Summary In the early days of the COVID-19 pandemic, New York Presbyterian Weill …

5034. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33642/psn-pdf
      November 01, 2006 - In Conversation With...Donald A. Norman, PhD November 1, 2006 In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you become interested…

5035. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49462/psn-pdf
      October 01, 2004 - Thin Air October 1, 2004 Gaba DM. Thin Air. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/thin-air Case Objectives Identify the gas-specific non-interchangeable connectors used for bulk gas supply outlets in hospitals. Define forcing function, both in engineered safety devices and in human procedures. R…

5036. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33722/psn-pdf
      December 01, 2011 - In Conversation With… Ann L. Hendrich, RN, PhD December 1, 2011 In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd Editor's note: Ann L. Hendrich, RN, PhD, is Vice President of Clinical Excellence Operations and Executive Di…

5037. Approach to Improving Patient Safety: Communication | PSNet
      psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
      August 31, 2020 - Annual Perspective Approach to Improving Patient Safety: Communication March 10, 2021  View more articles from the same authors. Citation Text: Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. Ro…

5038. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33697/psn-pdf
      June 01, 2010 - What Do We Know About Emergency Department Safety? June 1, 2010 Sklar DP, Crandall CS. What Do We Know About Emergency Department Safety? PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety Perspective Emergency medicine has evolved from a location, with var…

5039. 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 …

5040. Say It Again | PSNet
      psnet.ahrq.gov/web-mm/say-it-again
      January 31, 2020 - Say It Again Citation Text: Henriksen K, Hall KK. Say It Again. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …