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  1. Psn-Pdf (pdf file)

    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 …
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Spotlight (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. 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…
  9. 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…
  10. 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: …
  11. 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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. 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…
  15. 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…
  16. 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://…
  17. 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 …
  18. 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…
  19. Psn-Pdf (pdf file)

    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-…
  20. Spotlight (pdf file)

    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…

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