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psnet.ahrq.gov/node/49445/psn-pdf
May 01, 2004 - No Blood, Please
May 1, 2004
Liang BA. No Blood, Please. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/no-blood-please
The Case
A young woman, about 30 years of age, was injured in an automobile collision. She was brought to the
emergency department (ED) via ambulance, where she was found to be suffering …
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psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
January 01, 2019 - : Ulfat Shaikh, MD, MPH & Patricia Poole, PharmD, BCPS
○ Managing Editor: Meghan Weyrich, MPH
2
Objectives … decision-guides/
https://psnet.ahrq.gov/primer/duty-hours-and-patient-safety
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psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
November 01, 2016 - Case Objectives
Recognize the importance of eliciting patient preferences and goals of care at the … Access Hospitals and Dual Eligible Hospitals Attesting to CMS EHR Incentive Program Modified Stage 2: Objectives … PubMedId RIS
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - Case Objectives Identify the key aspects of the closed-loop blood delivery pathway and how they ensure … system that documents processes, procedures, and responsibilities for achieving quality policies and objectives … PubMedId RIS
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psnet.ahrq.gov/issue/preventable-errors-operating-room-retained-foreign-bodies-after-surgery-part-i
April 28, 2021 - Review
Preventable errors in the operating room: retained foreign bodies after surgery--part I.
Citation Text:
Gibbs VC, Coakley FD, Reines D. Preventable errors in the operating room: retained foreign bodies after surgery--Part I. Curr Probl Surg. 2007;44(5):281-337.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.110_slideshow.ppt
December 01, 2005 - School of Medicine
Spotlight Editor: Tracy Minichiello, MD
Managing Editor: Erin Hartman, MS
Objectives
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.76_slideshow.ppt
October 01, 2004 - Robert Wachter, MD
Spotlight Editor: Tracy Minichiello, MD
Managing Editor: Erin Hartman, MS
Objectives
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.197_slideshow.ppt
April 01, 2009 - Creighton University
Editor, AHRQ WebM&M: Robert Wachter, MD
Managing Editor: Erin Hartman, MS
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psnet.ahrq.gov/issue/high-cost-retained-surgical-items
February 22, 2023 - Newspaper/Magazine Article
The high cost of retained surgical items.
Citation Text:
The high cost of retained surgical items. Moorehead LD. Outpatient Surgery. April 5, 2023.
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psnet.ahrq.gov/issue/unintentionally-retained-guidewires-descriptive-study-73-sentinel-events
April 27, 2019 - Study
Unintentionally retained guidewires: a descriptive study of 73 sentinel events.
Citation Text:
Steelman VM, Thenuwara K, Shaw C, et al. Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events. Jt Comm J Qual Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.0…
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psnet.ahrq.gov/issue/surgical-complications-disclosing-adverse-events-and-medical-errors
September 23, 2020 - Commentary
Surgical complications: disclosing adverse events and medical errors.
Citation Text:
Wang AS, Eisen DB. Surgical complications: disclosing adverse events and medical errors. J Am Acad Dermatol. 2013;68(1):144-6. doi:10.1016/j.jaad.2012.09.008.
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psnet.ahrq.gov/web-mm/no-blood-please
January 14, 2011 - No Blood, Please
Citation Text:
Liang BA. No Blood, Please. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/missing-suction-tip
January 01, 2006 - Case Objectives Identify the risk factors for retained foreign bodies. … PubMedId RIS
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - foundational principle and overarching goal of the Healthy People 2030 action plan that includes objectives … health literacy – both personal and organizational – is essential to achieving all of Healthy People’s objectives
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psnet.ahrq.gov/issue/improving-safety-operating-room-systematic-literature-review-retained-surgical-sponges
March 05, 2025 - Review
Improving safety in the operating room: a systematic literature review of retained surgical sponges.
Citation Text:
Wan W, Le T, Riskin L, et al. Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol. 2009;22(…
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psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - Learning Objectives At the conclusion of this educational activity, participants should be able to: Describe … PubMedId RIS
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psnet.ahrq.gov/issue/designing-safer-process-prevent-retained-surgical-sponges-healthcare-failure-mode-and-effect
April 27, 2019 - Study
Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis.
Citation Text:
Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):1…
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psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
February 24, 2021 - Case Objectives Describe the myth of the "surgical personality" Identify features of highly reliable … PubMedId RIS
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - MPH and Ulfat Shaikh, MD
o Managing Editor: Meghan Weyrich, MPH
2
https://psnet.ahrq.gov/webmm
Objectives … Spotlight
Source and Credits
Objectives
False Assumptions Result in a Missed Pneumothorax after Bronchoscopy
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - a foundational principle and overarching goal of the
Healthy People 2030 action plan that includes objectives … health literacy – both personal and
organizational – is essential to achieving all of Healthy People’s objectives