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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - osteoarthritis, and spinal stenosis, status/post two previous 
spine surgeries and long-term use of opioid … analgesics
                                     
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - SPOTLIGHT CASE
         
 Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations 
 
 
 
 
 Citation Text: 
 Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese… 
                                     
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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - Annual Perspective 
 
 
 Diagnostic Errors 
 Urmimala Sarkar, MD; Kaveh Shojania, MD | January 1, 2014 
                       
 Also Read a Conversation  
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. Rockville (MD): Ag… 
                                     
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psnet.ahrq.gov/web-mm/need-eat
February 10, 2021 - (s) 
 
 
 
 
 
 
 Assessing reasons for decreased primary care access for individuals on prescribed opioids
                                     
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psnet.ahrq.gov/node/838221/psn-pdf
September 28, 2022 - We
know we can’t use opioids for chronic pain without the risk of creating addiction and overdose, so
                                     
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psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - Patient Mix-Up 
 
 
 
 
 Citation Text: 
 Shojania KG. Patient Mix-Up. 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/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - Chemotherapy Administration Safety Standards 
 
 
 
 
 Citation Text: 
 Bergsbaken J. Chemotherapy Administration Safety Standards. 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/weak-response
February 24, 2011 - A "Weak" Response 
 
 
 
 
 Citation Text: 
 Reisman AB. A "Weak" Response. 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/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
August 31, 2020 - nebulization, hospitals faced shortages of drugs such as  asthma medications and sedatives  and  injectable opioids
                                     
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psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
September 29, 2021 - SPOTLIGHT CASE
         
 Intraosseous Line Extravasation in a Pediatric Trauma Patient 
 
 
 
 
 Citation Text: 
 Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2… 
                                     
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psnet.ahrq.gov/web-mm/sloppy-and-paste
February 02, 2011 - Sloppy and Paste 
 
 
 
 
 Citation Text: 
 Hirschtick RE. Sloppy and Paste. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. 
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psnet.ahrq.gov/web-mm/troubling-amine
September 01, 2003 - A Troubling Amine 
 
 
 
 
 Citation Text: 
 Flynn EA. A Troubling Amine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. 
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psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap 
 
 
 
 
 Citation Text: 
 Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. 
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages 
 
 
 
 
 Citation Text: 
 Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. 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/solution-iv-or-irrigation-fluid-administration-errors-operating-room
January 29, 2021 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room. 
 
 
 
 
 Citation Text: 
 Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He… 
                                     
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Annual Perspective 
 
 
 Handoffs and Transitions 
 Niraj Sehgal, MD, MPH | January 22, 2014 
                       
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U… 
                                     
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psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
May 01, 2012 - Situational Awareness and Patient Safety 
 
 
 
 
 Citation Text: 
 Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. 
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psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation
March 27, 2024 - Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation 
 
 
 
 
 Citation Text: 
 Kulig CE, Ebong IA. Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. 
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - Annual Perspective 
 
 
 Rethinking Root Cause Analysis 
 Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD | January 1, 2016 
                       
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. Rockville (MD): Age… 
                                     
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
June 01, 2016 - I started at Sinai Health System 6 years ago, I focused on high-alert medications: anticoagulants, opioids