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psnet.ahrq.gov/node/50696/psn-pdf
November 27, 2019 - Complications of Vascular Access Procedures in Patients
with Kidney Disease
November 27, 2019
Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
The Ca…
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psnet.ahrq.gov/web-mm/mistaken-identity
December 18, 2014 - Mistaken Identity
Citation Text:
Hall LW. Mistaken Identity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49809/psn-pdf
October 01, 2017 - Hyperbilirubinemia Refractory to Phototherapy
October 1, 2017
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
The Case
A 1-day-old full-term infant was noted to have elevated total serum bilirubin (…
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psnet.ahrq.gov/node/49433/psn-pdf
June 23, 2021 - Environmental Safety in the OR
February 1, 2004
Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/environmental-safety-or
The Case
The infection control department of a hospital noticed a marked increase in the rates of post-operative
sternal wound inf…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
April 01, 2013 - Spotlight Case July 2008
Spotlight Case
Total Parenteral Nutrition, Multifarious Errors
*
*
Source and Credits
This presentation is based on the April 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Joseph I. Boullata, PharmD, RPh, BCNSP…
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psnet.ahrq.gov/web-mm/raise-bar
May 29, 2024 - Raise the Bar
Citation Text:
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - July Syndrome
June 1, 2016
Young JQ. July Syndrome. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/july-syndrome
The Case
A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower
lobe lung cancer. The attending surgeon saw the patient along with his fellow,…
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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - The Wrong Channel
September 1, 2005
Gosbee JW. The Wrong Channel . PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/wrong-channel
The Case
A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial
dosing started at 50 mL/hour using a multi-channel medication pump…
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psnet.ahrq.gov/web-mm/do-me-favor
September 12, 2016 - Do Me a Favor
Citation Text:
Williamson A. Do Me a Favor. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/850678/psn-pdf
June 14, 2023 - Advance Alert Monitor Program: An Automated Early
Warning System for Adults At Risk for In-Hospital Clinical
Deterioration
June 14, 2023
https://psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-
risk-hospital
Summary
To address a well-documented hospital adverse outco…
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psnet.ahrq.gov/perspective/conversation-charles-ornstein
October 01, 2009 - In Conversation with... Charles Ornstein
October 1, 2009
Also Read an Essay
Citation Text:
In Conversation with.. Charles Ornstein . PSNet [internet]. 2009.In Conversation with... Charles Ornstein . PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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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…
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety
Robert M. Wachter, MD | October 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wachter R. The Media: An Essential, If Sometimes Arbitrary, Pro…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
May 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer?
*
*
Source and Credits
This presentation is based on the May 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Sidney W.A. Dekker, Ph…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.197_slideshow.ppt
April 01, 2009 - Spotlight Case July 2008
Spotlight Case
Breakage of a PICC Line
*
*
Source and Credits
This presentation is based on the April 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Vesselin Dimov, MD
Creighton University
Editor, AHRQ WebM&M: …
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psnet.ahrq.gov/node/33560/psn-pdf
June 15, 2024 - Disclosure of Errors
June 15, 2024
Disclosure of Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/disclosure-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed…
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psnet.ahrq.gov/node/33559/psn-pdf
December 15, 2024 - Medication Reconciliation
December 15, 2024
Medication Reconciliation. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/medication-reconciliation
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…
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psnet.ahrq.gov/node/84413/psn-pdf
February 23, 2022 - or used on patients” and relevant financial
relationships as “financial relationships in any amount occurring
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psnet.ahrq.gov/node/33765/psn-pdf
April 01, 2014 - Where I see those
partnerships occurring, I've seen just incredible innovation and effectiveness.
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psnet.ahrq.gov/node/33828/psn-pdf
March 01, 2017 - MDW: Actually, just as we're talking it's occurring to me your intervention in the English health system