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4941. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement | PSNet
      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…

4942. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
      January 01, 2024 - Spotlight Spotlight A Fatal Twist in Pseudohyperkalemia 1 Source and Credits This presentation is based on the August 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Le…

4943. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33608/psn-pdf
      February 01, 2024 - Maternal Safety January 31, 2024 Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/primer/maternal-safety Originally published in 2018 by researchers at the University of California, San Francisco. Updated in February 2024 by Marla Shauer, PhD(c), MSN, CNM, Amy Nichols,…

4944. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety | PSNet
      psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
      December 01, 2012 - SPOTLIGHT CASE "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety Citation Text: Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…

4945. An Incomplete Anesthesia History Leads to Adverse Outcomes | PSNet
      psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
      January 29, 2021 - An Incomplete Anesthesia History Leads to Adverse Outcomes Citation Text: Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …

4946. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33856/psn-pdf
      April 01, 2018 - Patient Safety During Hospital Discharge April 1, 2018 Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge Perspective Patients are admitted to the hospital in the United States 35 million times per year.(1)…

4947. Medication Overdose | PSNet
      psnet.ahrq.gov/web-mm/medication-overdose
      September 01, 2011 - Medication Overdose Citation Text: Kaushal R. Medication Overdose. 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 PubMedId RI…

4948. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
      December 01, 2013 - PowerPoint Presentation Spotlight Case New Oral Anticoagulants 1 This presentation is based on the December 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Margaret C. Fang, MD, MPH, University of California, San Francisco Editor, AHRQ WebM&M…

4949. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33694/psn-pdf
      April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA April 1, 2010 In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a priva…

4950. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73549/psn-pdf
      July 28, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty. July 28, 2021 Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty The Case A 61-year-old male patient weighing 57…

4951. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49572/psn-pdf
      October 01, 2008 - Mistaken Identity October 1, 2008 Hall LW. Mistaken Identity. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/mistaken-identity The Case An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status and a reported fall. After finding tenderness in her left hip, the p…

4952. The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm | PSNet
      psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-reducing-inpatient-harm
      February 26, 2025 - The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL January 5, 2021 Innovation Contact …

4953. Strengthening the Business Case for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
      May 01, 2013 - Strengthening the Business Case for Patient Safety Peter K. Lindenauer, MD, MSc | May 1, 2013  Also Read a Conversation View more articles from the same authors. Citation Text: Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. …

4954. In Conversation With... Jack Westfall, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
      September 28, 2022 - In Conversation With... Jack Westfall, MD, MPH September 28, 2022  Also Read the Essay Citation Text: In Conversation With.. Jack Westfall, MD, MPH. PSNet [internet]. 2022.In Conversation With... Jack Westfall, MD, MPH. PSNet [internet]. Rockville (MD): Agency for…

4955. In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances | PSNet
      psnet.ahrq.gov/perspective/conversation-elizabeth-salisbury-afshar-about-harm-reduction-strategies-improve-safety
      October 30, 2024 - In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd | October 30, 2024  Also Read the Essay View more articles from the same auth…

4956. Harm Reduction Strategies to Improve Safety for People Who Use Substances | PSNet
      psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-who-use-substances
      October 30, 2024 - Harm Reduction Strategies to Improve Safety for People Who Use Substances Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd | October 30, 2024  Also Read the Conversation View more articles from the same authors. Citation Text: Salisbury-…

4957. Building a Safety Program in a Vast Health Care Network | PSNet
      psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
      March 01, 2019 - Building a Safety Program in a Vast Health Care Network Paul E. Phrampus, MD | March 1, 2019  Also Read a Conversation View more articles from the same authors. Citation Text: Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet].…

4958. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866261/psn-pdf
      July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery July 10, 2024 Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…

4959. Removing Insult from Injury—Disclosing Adverse Events | PSNet
      psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
      February 01, 2006 - Removing Insult from Injury—Disclosing Adverse Events Albert W. Wu, MD, MPH | February 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Wu AW. Removing Insult from Injury—Disclosing Adverse Events. PSNet [internet]. Rock…

4960. Patient Safety in the Physician Office Setting | PSNet
      psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
      November 04, 2015 - Patient Safety in the Physician Office Setting Nancy C. Elder, MD, MSPH | May 1, 2006  View more articles from the same authors. Citation Text: Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…