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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - SPOTLIGHT CASE
Unexplained Apnea Under Anesthesia
Citation Text:
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/863308/psn-pdf
February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in
Death During Endoscopy
February 28, 2024
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
The Case
A…
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psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
September 23, 2024 - ABCDEF Bundle + Data Literacy Training, Performance Measurement Tracking, and Performance Feedback
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February 28, 2024
Innovation
Conta…
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
Citation Text:
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/death-pca
January 06, 2017 - Death by PCA
Citation Text:
Hicks RW. Death by PCA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/node/49648/psn-pdf
March 01, 2012 - Postdischarge Follow-Up Phone Call
March 1, 2012
Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
Case Objectives
Understand why preventing readmissions through postdischarge phone calls is important.
Describe evidence su…
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy
Citation Text:
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/web-mm/caution-interrupted
October 01, 2016 - Caution, Interrupted
Citation Text:
Wears RL. Caution, Interrupted. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/60173/psn-pdf
March 30, 2020 - In Conversation With... Ann Gaffey, RN, MSN, CPHRM and
Bruce Spurlock, MD
March 30, 2020
In Conversation With.. Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
Editor’s note: Ann D. Gaffey, RN, …
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psnet.ahrq.gov/issue/pain-was-unbearable-so-why-did-doctors-turn-her-away
November 25, 2020 - Newspaper/Magazine Article
The pain was unbearable. So why did doctors turn her away?
Citation Text:
The pain was unbearable. So why did doctors turn her away? Szalavitz M. Wired Magazine. August 11, 2021.
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psnet.ahrq.gov/issue/ucsd-doc-who-overdosed-hospital-bathroom-face-lawsuits
March 27, 2024 - Newspaper/Magazine Article
UCSD, doc who overdosed in hospital bathroom face lawsuits.
Citation Text:
UCSD, doc who overdosed in hospital bathroom face lawsuits. Clark C. MedPage Today. February 10, 2020.
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psnet.ahrq.gov/issue/conversation-among-stakeholders-medical-malpractice
January 11, 2023 - Meeting/Conference Proceedings
A Conversation Among Stakeholders on Medical Malpractice.
Citation Text:
A Conversation Among Stakeholders on Medical Malpractice. Collaborative for Accountability and Improvement. April 26, 2022.
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psnet.ahrq.gov/issue/work-design-drivers-organizational-learning-about-operational-failures-laboratory-experiment
September 05, 2012 - Book/Report
Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration.
Citation Text:
Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration. Tuc…
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psnet.ahrq.gov/issue/using-machine-learning-improve-patient-safety-home-or-remote-setting-adults
May 25, 2022 - Book/Report
Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults.
Citation Text:
Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults. Feske-Kirby K, Whittington J, McGaffigan P. Boston, MA: Institute for Healthcar…
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psnet.ahrq.gov/issue/inadvertent-administration-oral-liquid-medicine-vein
January 22, 2020 - Book/Report
Inadvertent Administration of an Oral Liquid Medicine into a Vein.
Citation Text:
Inadvertent Administration of an Oral Liquid Medicine into a Vein. Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.
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psnet.ahrq.gov/issue/organisational-failure-exploratory-study-steel-industry-and-medical-domain
June 02, 2010 - Book/Report
Organisational Failure: An Exploratory Study in the Steel Industry and Medical Domain.
Citation Text:
Organisational Failure: An Exploratory Study in the Steel Industry and Medical Domain. van Vuuren W. Eindhoven, NL; Eindhoven University of Technology: 1998. ISBN 9038605…
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psnet.ahrq.gov/issue/2011-annual-benchmarking-report-malpractice-risks-emergency-medicine
July 18, 2018 - Book/Report
2011 Annual Benchmarking Report: Malpractice Risks in Emergency Medicine.
Citation Text:
2011 Annual Benchmarking Report: Malpractice Risks in Emergency Medicine. Ruoff G, ed. Cambridge, MA: CRICO Strategies; 2012.
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psnet.ahrq.gov/issue/mri-suites-safety-outside-bore
April 28, 2021 - Commentary
MRI suites: safety outside the bore.
Citation Text:
MRI suites: safety outside the bore. Gilk T. Patient Safety and Quality Healthcare. September/October 2006:1-8.
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psnet.ahrq.gov/issue/investigation-role-clinical-pharmacy-services-helping-identify-and-reduce-high-risk
September 29, 2021 - Book/Report
Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk Prescribing Errors in Hospital.
Citation Text:
Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk Prescribing Errors in Hos…
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psnet.ahrq.gov/issue/medicine-safety-take-care
February 21, 2018 - Book/Report
Medicine Safety: Take Care.
Citation Text:
Medicine Safety: Take Care. Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019.
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