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Showing results for "mechanisms".

  1. Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx Spotlight Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation Source and Credits • This presentation is based on the March 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/…

  2. One Toxic Drug Is Not Like Another | PSNet

    psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
    October 02, 2019 - SPOTLIGHT CASE One Toxic Drug Is Not Like Another Citation Text: Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTe…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866826/psn-pdf
    September 25, 2024 - Hypoxic Gas Supply from Cross-Connected Pipelines September 25, 2024 Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines The Case An 8-year-old boy with no significant past medical…

  4. Airway Obstruction during Anterior Cervical Spine Surgery | PSNet

    psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
    January 29, 2021 - Airway Obstruction during Anterior Cervical Spine Surgery Citation Text: Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …

  5. Maternal Safety | PSNet

    psnet.ahrq.gov/curated-library/maternal-safety
    January 31, 2024 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Maternal Safety  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team …

  6. Implementation of Patient Safety Projects | PSNet

    psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
    August 10, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Implementation of Patient Safety Projects  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybraria…

  7. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet

    psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
    October 01, 2004 - SPOTLIGHT CASE Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Citation Text: Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…

  8. Isolated Clot, Real Error | PSNet

    psnet.ahrq.gov/web-mm/isolated-clot-real-error
    December 01, 2013 - SPOTLIGHT CASE Isolated Clot, Real Error Citation Text: Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  9. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet

    psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
    August 01, 2009 - Misplaced Nasogastric Tube Resulting in Aspiration Citation Text: Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google S…

  10. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. | PSNet

    psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
    January 29, 2021 - Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. Citation Text: Bohringer C. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.. PSNet [internet]. Rockville (MD): Agency for He…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867429/psn-pdf
    December 18, 2024 - reapproximated, dural flaps cannot remain adhered at the durotomy site and CSF leak is more likely.14 Both mechanisms—CSF

  12. The Deadly Duo | PSNet

    psnet.ahrq.gov/web-mm/deadly-duo
    April 28, 2021 - The Deadly Duo Citation Text: Maldonado JR. The Deadly Duo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  13. Unseen Perils of Urinary Catheters | PSNet

    psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
    January 31, 2024 - Unseen Perils of Urinary Catheters Citation Text: Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar Bib…

  14. Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective | PSNet

    psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-registered-nurses-perspective
    June 01, 2016 - Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective Karen Frank, DNP, RN, MSHA | June 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Frank K. Becoming a Certified Professional in Patien…

  15. In Conversation with...Brent C. James, MD, MStat | PSNet

    psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
    February 26, 2025 - In Conversation with...Brent C. James, MD, MStat February 1, 2011  Citation Text: In Conversation with..Brent C. James, MD, MStat. PSNet [internet]. 2011.In Conversation with...Brent C. James, MD, MStat. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…

  16. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers | PSNet

    psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
    January 07, 2022 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers Citation Text: Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

  17. Hidden Heparins: HIT Happens | PSNet

    psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
    March 27, 2024 - SPOTLIGHT CASE Hidden Heparins: HIT Happens Citation Text: Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  18. 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…

  19. 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…

  20. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
    January 01, 2024 - Spotlight Spotlight Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Christian Bohringer, MBBS, …
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