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psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - Sudden Collapse During Upper Gastrointestinal
Endoscopy: Expect the Unexpected
August 25, 2021
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-
unexpected
…
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - But See the Patient First
January 29, 2021
Sinigayan VR. But See the Patient First. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/see-patient-first
The Case
A 55-year-old man with acute myeloid leukemia presented to the emergency department (ED) with a chief
complaint of fever. Five days previously, he…
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - Missed CANDOR Implementation Opportunities.
November 16, 2022
Schweitzer L. Missed CANDOR Implementation Opportunities. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
The Case
A 58-year-old man with a history of type 2 diabetes mellitus, hypertension, morbid obesit…
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psnet.ahrq.gov/node/74021/psn-pdf
October 25, 2021 - In Conversation With... Georgia Galanou Luchen, Pharm.
D.
October 25, 2021
In Conversation With.. Georgia Galanou Luchen, Pharm. D. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-georgia-galanou-luchen-pharm-d
Editor’s Note: Georgia Galanou Luchen, Pharm. D., is the Director of Member Rela…
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Patient Safety Events Involving Opioid
Dose Stacking
Source and Credits
• This presentation is based on the January 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
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psnet.ahrq.gov/node/866622/psn-pdf
August 28, 2024 - In Conversation with Chalapathy Venkatesan and Kathy
Helak about Application of Safety-II Principles
August 28, 2024
In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-an…
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psnet.ahrq.gov/node/49744/psn-pdf
October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced
Hemolysis in a Patient With a Known Allergy
October 1, 2015
Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known
Allergy. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…
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psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
July 10, 2024 - In Conversation with...Patrick S. Romano, MD, MPH
November 1, 2010
Citation Text:
In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.In Conversation with...Patrick S. Romano, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
March 01, 2007 - The Role of the Patient in Improving Patient Safety
Rosemary Gibson, MSc | March 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. Rockville…
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens
Citation Text:
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citation
Format:
…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest
Citation Text:
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…
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psnet.ahrq.gov/node/61082/psn-pdf
July 23, 2020 - Long-Term Care and the Response to COVID-19
October 28, 2020
Popejoy LL, Crecelius CA, Fitall E, et al. Long-Term Care and the Response to COVID-19. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/long-term-care-and-response-covid-19
The COVID-19 pandemic has had far-reaching consequences on how the hea…
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psnet.ahrq.gov/node/49771/psn-pdf
July 01, 2016 - Unintended Consequences of CPOE
October 1, 2016
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
Case Objectives
Explain how technology, including computerized provider order entry, can transform, rather than
eliminate, hazards.
Recogni…
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psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - Advancing Patient Safety Through State Reporting Systems
Jill Rosenthal, MPH | June 1, 2007
View more articles from the same authors.
Citation Text:
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - SPOTLIGHT CASE
Transfer Troubles
Citation Text:
Hains IM. Transfer Troubles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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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 - Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx
Spotlight
Respiratory Distress after Neck Surgery: Two
Cases of Post-Operative Cervical Hematoma
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - SPOTLIGHT CASE
False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.
Citation Text:
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.
Citation Text:
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
March 27, 2024
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and
Emergency Hysterectomy. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care
Source and Credits
• This presentation is based on the 2020 AHRQ WebM&M Spotlight
Case
○ See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD
○ Editor…