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psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
February 26, 2025 - Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner
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psnet.ahrq.gov/node/49662/psn-pdf
August 01, 2012 - Wrong Turn through Colon: Misplaced PEG
August 1, 2012
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
The Case
An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…
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psnet.ahrq.gov/node/49529/psn-pdf
February 01, 2007 - Crossed Coverage
February 1, 2007
Kayser SR. Crossed Coverage. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/crossed-coverage
The Case
A 27-year-old woman with a history of congenital heart disease was admitted for cardiac transplantation
evaluation. She had already undergone multiple surgeries, including…
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psnet.ahrq.gov/node/851555/psn-pdf
July 31, 2023 - Bandemia as a Harbinger of Stercoral Colitis and
Impending Perforation
July 31, 2023
Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
The Case
A 56-year-…
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psnet.ahrq.gov/node/49665/psn-pdf
September 01, 2012 - Undetected Foreign Object
September 1, 2012
Cima RR. Undetected Foreign Object. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/undetected-foreign-object
The Case
A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension,
and diabetes was found to have obstruct…
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psnet.ahrq.gov/node/49728/psn-pdf
March 01, 2015 - Medication Mix-Up: From Bad to Worse
March 1, 2015
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/medication-mix-bad-worse
The Case
A 69-year-old man with chronic kidney disease and essential hypertension was admitted to the hospital
with chest …
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psnet.ahrq.gov/node/50612/psn-pdf
October 30, 2019 - The Safety Challenges of Supervision and Night Coverage
in Academic Residency
October 30, 2019
Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
The Case…
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psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
December 21, 2018 - A Fumbled Handoff to Inpatient Rehab
Citation Text:
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
July 02, 2011 - Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.
Citation Text:
DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
September 01, 2004 - Milliliters vs. Milligrams
Citation Text:
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - Managing Ascites: Hazards of Fluid Removal
Citation Text:
Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/nosy-business
March 01, 2007 - Nosy Business
Citation Text:
Orlandi RR. Nosy Business. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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…
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psnet.ahrq.gov/node/33711/psn-pdf
May 01, 2011 - The Second Victim Phenomenon: A Harsh Reality of
Health Care Professions
May 1, 2011
Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [internet].
2011.
https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
Perspective
The Instit…
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psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - January 15, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
June 15, 2024 - Inpatient Transitions of Care: Challenges and Safety Practices
Citation Text:
Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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…
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psnet.ahrq.gov/web-mm/2-week-itch
June 16, 2019 - The 2-Week Itch
Citation Text:
Cohen MR. The 2-Week Itch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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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.
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Format…
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psnet.ahrq.gov/node/49591/psn-pdf
October 01, 2009 - Difficult Encounters: A CMO and CNO Respond
October 1, 2009
Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
Case Objectives
Appreciate the risk of disruptive behavior and understand institutional respons…
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psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
January 01, 2022 - Spotlight
Spotlight
Fecal Contamination of the Peritoneum from
Laparoscopic Trocar Injury: A Routine
Operation Goes Wrong
Source and Credits
• This presentation is based on the October 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary…
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - Syringe Swap During Regional Block: A Case of
Medication Error and Recovery
January 31, 2024
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…