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4881. The Literature on Health Care Simulation Education: What Does It Show? | PSNet
      psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show
      March 01, 2013 - The Literature on Health Care Simulation Education: What Does It Show? David A. Cook, MD, MHPE | March 1, 2013  Also Read a Conversation View more articles from the same authors. Citation Text: Cook DA. The Literature on Health Care Simulation Education: What Do…

4882. Adolescent Diabetes: A Routine Visit? | PSNet
      psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
      November 18, 2016 - SPOTLIGHT CASE Adolescent Diabetes: A Routine Visit? Citation Text: Slap GB. Adolescent Diabetes: A Routine Visit?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar Bi…

4883. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33858/psn-pdf
      May 01, 2018 - In Conversation With… John Halamka, MD, MS May 1, 2018 In Conversation With… John Halamka, MD, MS. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms Editor's note: Dr. Halamka is the International Healthcare Innovation Professor at Harvard Medical School, Chief Information …

4884. Maternal Safety | PSNet
      psnet.ahrq.gov/primer/maternal-safety
      January 10, 2024 - Maternal Safety Citation Text: Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

4885. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50931/psn-pdf
      February 26, 2020 - Timely diagnosis of esophageal perforation February 26, 2020 Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation The Case  A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…

4886. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866265/psn-pdf
      July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport July 31, 2024 MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…

4887. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49866/psn-pdf
      June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the Operating Room June 1, 2019 Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room The Case A 43-year-old woman was admi…

4888. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49845/psn-pdf
      October 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages October 1, 2018 Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages The Case A 1-month-old preterm infant in the ne…

4889. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
      August 01, 2015 - PowerPoint Presentation Spotlight Privacy or Safety? 1 This presentation is based on the July/August 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John D. Halamka, MD, MS, Beth Israel Deaconess Medical Center; and Deven McGraw, JD, MPH, LLM…

4890. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33681/psn-pdf
      March 01, 2009 - The Role of Health Literacy in Patient Safety March 1, 2009 Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/role-health-literacy-patient-safety Perspective Clear health communication is increasingly recognized as essential for promoting …

4891. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49868/psn-pdf
      July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With Dementia July 2, 2019 Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia The Case An 86-year-old man with neurode…

4892. Missing Trauma | PSNet
      psnet.ahrq.gov/web-mm/missing-trauma
      March 03, 2011 - Missing Trauma Citation Text: Jurkovich GJ. Missing Trauma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

4893. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. | PSNet
      psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
      October 27, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty. Citation Text: Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format…

4894. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49417/psn-pdf
      October 01, 2003 - Lost in the Black Hole October 1, 2003 Wachter R. Lost in the Black Hole. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lost-black-hole The Case A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis. She had a remote history of gonorrhea, no environmental exposu…

4895. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49856/psn-pdf
      March 01, 2019 - Premature Extubation March 1, 2019 Sagana R, Hyzy RC. Premature Extubation. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/premature-extubation The Case A 73-year-old woman with a history of carotid artery stenosis was admitted for an elective carotid endarterectomy. The procedure was initially thought to …

4896. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49863/psn-pdf
      May 01, 2019 - Good Catch in the Operating Room May 1, 2019 Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/good-catch-operating-room The Case A 46-year-old woman with extensive history of back pain from lumbar stenosis was scheduled for an elective laminectomy and spinal…

4897. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49489/psn-pdf
      September 01, 2005 - Double Trouble September 1, 2005 Gurwitz JH. Double Trouble. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/double-trouble Case Objectives Appreciate the incidence of adverse drug events in older persons List preventative measures that can be used to minimize medication errors in this population Encourage…

4898. Lost in the Black Hole | PSNet
      psnet.ahrq.gov/web-mm/lost-black-hole
      December 01, 2005 - Lost in the Black Hole Citation Text: Wachter R. Lost in the Black Hole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

4899. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet
      psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
      August 01, 2012 - SPOTLIGHT CASE The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Citation Text: Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

4900. Out of Sight, Out of Mind: Out-of-Office Test Result Management | PSNet
      psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
      September 01, 2007 - SPOTLIGHT CASE Out of Sight, Out of Mind: Out-of-Office Test Result Management Citation Text: Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …