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4721. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853773/psn-pdf
      September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…

4722. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49864/psn-pdf
      June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…

4723. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33746/psn-pdf
      March 01, 2013 - In Conversation With… David M. Gaba, MD March 1, 2013 In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of Medicine. An international leade…

4724. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49799/psn-pdf
      July 01, 2017 - Delayed Recognition of a Positive Blood Culture July 1, 2017 Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture The Case A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…

4725. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49654/psn-pdf
      June 01, 2012 - Transfer Troubles June 1, 2012 Hains IM. Transfer Troubles. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfer-troubles Case Objectives Recognize that transfer of patients between hospitals is common. Understand the frequency of errors and adverse events in the transfer of patients between hospitals. …

4726. 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.…

4727. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49793/psn-pdf
      May 01, 2017 - Hemolysis Holdup May 1, 2017 Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hemolysis-holdup The Case A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…

4728. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
      June 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case June 2004 The Wrong Shot: Error Disclosure Source and Credits This presentation is based on the June 2004 AHRQ WebM&M Spotlight Case in Pediatrics CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Commentary by: Thomas H. …

4729. 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…

4730. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
      January 01, 2024 - Spotlight Spotlight A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Elizabeth Gould, NP-C, COR…

4731. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49816/psn-pdf
      January 01, 2018 - A Painful Medication Reconciliation Mishap January 1, 2018 Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap Case Objectives Recognize that substance use disorders are common in patients with acute pain. Understand th…

4732. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846768/psn-pdf
      March 29, 2023 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. March 29, 2023 Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery The Ca…

4733. Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
      January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx Spotlight Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the ful…

4734. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33875/psn-pdf
      March 01, 2019 - In Conversation With… Susan Haas, MD, MSc March 1, 2019 In Conversation With… Susan Haas, MD, MSc. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc Editor's note: Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs' work focused on health…

4735. Hyperbilirubinemia Refractory to Phototherapy | PSNet
      psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
      March 01, 2006 - Hyperbilirubinemia Refractory to Phototherapy Citation Text: Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar …

4736. In Conversation with...Dean Schillinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
      March 01, 2009 - In Conversation with...Dean Schillinger, MD March 22, 2009  Also Read an Essay Citation Text: In Conversation with..Dean Schillinger, MD. PSNet [internet]. 2009.In Conversation with...Dean Schillinger, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Re…

4737. Spotlight Case (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
      August 01, 2012 - Spotlight Case Spotlight Case No News May Not Be Good News 1 2 Source and Credits This presentation is based on the August 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…

4738. Hemolysis Holdup | PSNet
      psnet.ahrq.gov/web-mm/hemolysis-holdup
      July 03, 2016 - Hemolysis Holdup Citation Text: Lehman CM. Hemolysis Holdup. 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 XML EndNote 7 XML Endnote tagged PubMedId RIS …

4739. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60611/psn-pdf
      June 24, 2020 - Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing June 24, 2020 Giannini J, Wong M, Dager W, et al. Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk…

4740. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865655/psn-pdf
      April 24, 2024 - Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. April 24, 2024 Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-comp…