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  1. psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
    January 01, 2024 - Spotlight Spotlight A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis 1 Source and Credits This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Garth Utter, MD, MSc, FACS…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836841/psn-pdf
    June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission April 7, 2022 https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and- paramedics-provide-home Sum…
  3. psnet.ahrq.gov/web-mm/good-catch-operating-room
    August 27, 2017 - Good Catch in the Operating Room Citation Text: Day J, Paige JT. Good Catch in the Operating Room. 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 …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865778/psn-pdf
    May 29, 2024 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement May 29, 2024 Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-complications-unint…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49531/psn-pdf
    March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857259/psn-pdf
    November 30, 2023 - Medication Mix-Up Leads to Patient Death November 30, 2023 Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death The Case  An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
  7. 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…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49402/psn-pdf
    June 01, 2003 - Inappropriate Antibiotic Use June 1, 2003 Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use The Case A 41-year-old woman presented to the hospital with acute renal failure, which came to be diagnosed as a first presentation of s…
  9. psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
    March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose Citation Text: Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33714/psn-pdf
    July 01, 2011 - In Conversation with…William B. Munier, MD, MBA July 1, 2011 In Conversation with…William B. Munier, MD, MBA. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba Editor's note: William B. Munier, MD, MBA, is the Director of the Center for Quality Improvement and Pati…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855057/psn-pdf
    October 31, 2023 - Addressing Workplace Violence and Creating a Safer Workplace October 31, 2023 Jones CB, Sousane Z, Mossburg S. Addressing Workplace Violence and Creating a Safer Workplace. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace While violence in the w…
  12. psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
    February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency Citation Text: Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…
  13. psnet.ahrq.gov/web-mm/thin-air
    March 01, 2006 - SPOTLIGHT CASE Thin Air Citation Text: Gaba DM. Thin Air. 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 …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73456/psn-pdf
    June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia June 30, 2021 Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…
  15. psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
    September 01, 2017 - Missed Patient Assignment: Is Anyone There? Citation Text: Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49669/psn-pdf
    November 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.…
  17. meps.ahrq.gov/data_files/publications/st374/stat374.shtml
    July 01, 2012 - STATISTICAL BRIEF #374: Changes in Adult Asthma Medication Use and Expenditures, United States, 1998-1999 to 2008-2009   Skip to main content An official website of the Department of Health & Human Services …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860050/psn-pdf
    January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic Infant. January 4, 2024 Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant The Case A 2-month-old full-term male infant was b…
  19. psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
    July 08, 2022 - Medication Mix-Up Leads to Patient Death Citation Text: Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX En…
  20. psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
    February 23, 2022 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement Citation Text: Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…