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  1. psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
    May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room. Citation Text: Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60542/psn-pdf
    May 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride May 27, 2020 Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride The Case  An infant with trisomy 21 underwent repair of a…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73153/psn-pdf
    April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough April 28, 2021 Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough Disclosure of Relev…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72516/psn-pdf
    November 25, 2020 - Premature Closure: Was It Just Syncope? November 25, 2020 Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
  5. psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx Spotlight Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes Source and Credits • This presentation is based on the April 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/we…
  6. psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
    March 27, 2024 - SPOTLIGHT CASE "Do You Want Everything Done?": Clarifying Code Status Citation Text: Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. …
  7. psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx Spotlight A Missed Bowel Perforation – the Importance of Diagnostic Reasoning Source and Credits • This presentation is based on the September 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/web…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843150/psn-pdf
    December 05, 2022 - In Conversation with... Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population February 1, 2023 In Conversation with.. Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-connor-wesley-rn-bsn-patie…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846126/psn-pdf
    March 09, 2023 - Medication Handling and Compounding Errors in the Operating Room. March 15, 2023 Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room The Case A 62-y…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72614/psn-pdf
    March 01, 2021 - Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes Originally published on December 22, 2020 Last updated on December 23, 2020 https://psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads- improved-outcomes Summary Multidisciplinary tea…
  11. psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
    July 01, 2017 - SPOTLIGHT CASE “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event Citation Text: Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
  12. psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
    January 31, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk Citation Text: Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quali…
  13. psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
    February 05, 2020 - Hypoxic Gas Supply from Cross-Connected Pipelines Citation Text: Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google S…
  14. psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
    February 26, 2025 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL July 31, 2023 Innovation Contact …
  15. psnet.ahrq.gov/web-mm/ebola-are-we-ready
    July 01, 2012 - Ebola: Are We Ready? Citation Text: Barsuk JH, Barnard C. Ebola: Are We Ready?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
  16. psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
    March 03, 2021 - SPOTLIGHT CASE Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. Citation Text: Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867359/psn-pdf
    December 18, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk December 18, 2024 Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/importance-following-saf…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851389/psn-pdf
    July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer Summary Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, a…
  19. psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
    August 14, 2024 - SPOTLIGHT CASE Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. Citation Text: Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866993/psn-pdf
    October 30, 2024 - In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances October 30, 2024 Salisbury-Afshar E, Gale B, Mossburg S. In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances. P…

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