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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49512/psn-pdf
    May 01, 2006 - Right? Left? Neither! May 1, 2006 Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/right-left-neither Case Objectives Appreciate the role of Reason's Swiss Cheese Model in medical errors Understand the process of analyzing a single error Provide suggestions for …

  2. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx Spotlight The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Source and Credits • This presentation is based on the November 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahr…

  3. A Loss of Trust and a Missed Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
    October 31, 2023 - SPOTLIGHT CASE A Loss of Trust and a Missed Diagnosis Citation Text: Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format:…

  4. Delayed Diagnosis of Mesenteric Ischemia | PSNet

    psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
    March 31, 2021 - SPOTLIGHT CASE Delayed Diagnosis of Mesenteric Ischemia Citation Text: Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …

  5. Updates in the Management of High-Risk Pulmonary Embolism | PSNet

    psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
    December 02, 2020 - Updates in the Management of High-Risk Pulmonary Embolism Citation Text: Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Forma…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33793/psn-pdf
    November 01, 2015 - In Conversation With… Kaveh Shojania, MD November 1, 2015 In Conversation With… Kaveh Shojania, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md Editor's note: Kaveh Shojania, MD, is Editor-in-Chief of BMJ Quality and Safety and Director of the Centre for Quality Impro…

  7. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure | PSNet

    psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
    March 01, 2005 - SPOTLIGHT CASE CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure Citation Text: Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…

  8. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures. | PSNet

    psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
    August 31, 2022 - SPOTLIGHT CASE Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures. Citation Text: Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867357/psn-pdf
    December 18, 2024 - Hypoxemia after Emergency Intubation December 18, 2024 Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation The Case A 19-month-old child was brought to the emergency department (ED) via ambulance after drowning in a p…

  10. Nothing Called Small Surgery | PSNet

    psnet.ahrq.gov/web-mm/nothing-called-small-surgery
    February 01, 2023 - Nothing Called Small Surgery Citation Text: Manske C. Nothing Called Small Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

  11. 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…

  12. In Conversation with Edwin Boudreaux about Suicide Prevention | PSNet

    psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
    March 25, 2025 - In Conversation with Edwin Boudreaux about Suicide Prevention Edwin Boudreaux, PhD; Bryan Gale, MA; Sarah Mossburg, Phd | March 24, 2025  Also Read the Essay View more articles from the same authors. Citation Text: Boudreaux E, Gale B, Mossburg SE. In Conversati…

  13. The Dropped "No" | PSNet

    psnet.ahrq.gov/web-mm/dropped-no
    October 30, 2019 - The Dropped "No" Citation Text: Johnson AJ. The Dropped "No". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  14. Preventable Rash | PSNet

    psnet.ahrq.gov/web-mm/preventable-rash
    October 01, 2012 - Preventable Rash Citation Text: McLean C. Preventable Rash. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49687/psn-pdf
    August 21, 2013 - Emergency Error August 21, 2013 Symons NRA. Emergency Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/emergency-error Case Objectives State that emergency surgery is high risk and has high mortality. Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of …

  16. Pocket Syringe Swap | PSNet

    psnet.ahrq.gov/web-mm/pocket-syringe-swap
    July 01, 2006 - Pocket Syringe Swap Citation Text: Kulli JC. Pocket Syringe Swap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49461/psn-pdf
    September 01, 2004 - Reaction to Dye September 1, 2004 Cohan R. Reaction to Dye. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/reaction-dye The Case A patient was referred to urology after having several episodes of gross hematuria. The urologist thought that the patient might have a renal mass and sent him to radiology for a…

  18. Too Much, Too Fast | PSNet

    psnet.ahrq.gov/web-mm/too-much-too-fast
    June 14, 2019 - Too Much, Too Fast Citation Text: Tuot D. Too Much, Too Fast. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49609/psn-pdf
    October 01, 2010 - Dangerous Dialysis October 1, 2010 Holley JL. Dangerous Dialysis . PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/dangerous-dialysis Case Objectives List common errors that occur in dialysis units. Describe steps that can be taken by dialysis units to prevent these common errors. Describe the role of the …

  20. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up | PSNet

    psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
    December 01, 2005 - An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up Robert M. Wachter, MD | June 1, 2012  View more articles from the same authors. Citation Text: Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. …
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