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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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Format:
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…
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psnet.ahrq.gov/node/852699/psn-pdf
August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety
August 30, 2023
Van CM, Mossburg S, McGaffigan P. Beyond the Pandemic: Creating Total Systems Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
The COVID-19 pandemic necessitated a shift in operations …
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psnet.ahrq.gov/node/60543/psn-pdf
May 27, 2020 - Wrong Catheter in the Right Patient
May 27, 2020
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
The Case
A 55-year-old man with history of emphysema was admitted to the hospital for pneumonia. The patient had
two?peripheral…
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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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psnet.ahrq.gov/node/49749/psn-pdf
December 01, 2015 - Hyperglycemia and Switching to Subcutaneous Insulin
December 1, 2015
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
The Case
A 47-year-old man with type 2 diabetes was admitted to the hospita…
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psnet.ahrq.gov/node/33853/psn-pdf
March 01, 2018 - In Conversation With… Linda Aiken, PhD, RN
March 1, 2018
In Conversation With… Linda Aiken, PhD, RN. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
Editor's note: Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and
Director of the Ce…
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psnet.ahrq.gov/node/60330/psn-pdf
May 05, 2020 - Telehealth and Patient Safety During the COVID-19
Response
May 14, 2020
Sikka N, Willis JS, Fitall E, et al. Telehealth and Patient Safety During the COVID-19 Response. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
Introduction
Telehealth typ…
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psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md
June 01, 2018 - In Conversation With… Richard Hoppmann, MD
June 1, 2018
Also Read an Essay
Citation Text:
In Conversation With… Richard Hoppmann, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
…
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - SPOTLIGHT CASE
Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome
Citation Text:
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet…
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psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
January 01, 2024 - Spotlight
Spotlight
Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis
1
Source and Credits
This presentation is based on the December 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Comment…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.281_slideshow.ppt
October 01, 2012 - the intensive care unit (ICU) because the patient was not stable enough to have it performed in the operating
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - : Fluid administration errors in the operating room.
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psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
July 02, 2019 - WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences in the Operating
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psnet.ahrq.gov/web-mm/poor-prognosis
March 15, 2016 - The patient was taken to the operating room for resection under general anesthesia.
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psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
January 07, 2015 - games with a system creates the potential for increased risk by placing users outside their normal operating
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psnet.ahrq.gov/web-mm/dont-push
March 02, 2011 - Impact of team performance on the surgical safety checklist on patient outcomes: an operating
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psnet.ahrq.gov/web-mm/inflicting-confusion
August 04, 2021 - March 23, 2012
Patient safety in the cardiac operating room: human factors and teamwork
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psnet.ahrq.gov/web-mm/chest-tube-complications
September 27, 2023 - WebM&M Cases
Medication Handling and Compounding Errors in the Operating
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Mitigating distractions in healthcare settings and implementing pre-test pauses, as operating rooms and
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psnet.ahrq.gov/web-mm/suicidal-man-gun
May 01, 2005 - Metaphorically, clinicians in situations like this can feel like they themselves are operating “under