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  1. Intraoperative Awareness during Rhinoplasty | PSNet

    psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
    January 29, 2021 - SPOTLIGHT CASE Intraoperative Awareness during Rhinoplasty Citation Text: Bohringer C, Toor J. Intraoperative Awareness during Rhinoplasty. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …

  2. Hidden Heparins: HIT Happens | PSNet

    psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
    March 27, 2024 - SPOTLIGHT CASE Hidden Heparins: HIT Happens Citation Text: Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  3. "Do You Want Everything Done?": Clarifying Code Status | PSNet

    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. …

  4. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet

    psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
    March 15, 2023 - SPOTLIGHT CASE Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Citation Text: Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. PSNet [internet]. Rockville (MD): Agency fo…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49537/psn-pdf
    June 01, 2007 - Beeline to Spine June 1, 2007 Smetana GW. Beeline to Spine. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/beeline-spine Case Objectives Understand the elements of preoperative medical evaluation. Appreciate the limited role for preoperative laboratory testing. Appreciate the importance of communication a…

  6. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer | PSNet

    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 …

  7. Monitoring Fetal Health | PSNet

    psnet.ahrq.gov/web-mm/monitoring-fetal-health
    September 08, 2010 - SPOTLIGHT CASE Monitoring Fetal Health Citation Text: Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNot…

  8. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon | PSNet

    psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
    January 29, 2021 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon Citation Text: Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853435/psn-pdf
    September 13, 2023 - Assessing the utility of ChatGPT throughout the entire clinical workflow: development and usability study. September 13, 2023 Rao A, Pang M, Kim J, et al. Assessing the utility of ChatGPT throughout the entire clinical workflow: development and usability study. J Med Internet Res. 2023;25:e48659. doi:10.2196/48659.…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60256/psn-pdf
    April 22, 2020 - A critical review: moral injury in nurses in the aftermath of a patient safety incident. April 22, 2020 Stovall M, Hansen L, van Ryn M. A critical review: moral injury in nurses in the aftermath of a patient safety incident. J Nurs Scholarsh. 2020;52(3):320-328. doi:10.1111/jnu.12551. https://psnet.ahrq.gov/issue/…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45274/psn-pdf
    July 20, 2016 - Medication safety in neonatal care: a review of medication errors among neonates. July 20, 2016 Krzyzaniak N, Bajorek B. Medication safety in neonatal care: a review of medication errors among neonates. Ther Adv Drug Saf. 2016;7(3):102-119. doi:10.1177/2042098616642231. https://psnet.ahrq.gov/issue/medication-safe…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60275/psn-pdf
    April 29, 2020 - Misreading injectable medications—causes and solutions: an integrative literature review. April 29, 2020 Borradale H, Andersen P, Wallis M, et al. Misreading injectable medications—causes and solutions: an integrative literature review. J Patient Saf. 2020. doi:10.1016/j.jcjq.2020.01.007. https://psnet.ahrq.gov/is…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48157/psn-pdf
    August 21, 2019 - Recommendations for using the Revised Safer Dx instrument to help measure and improve diagnostic safety. August 21, 2019 Singh H, Khanna A, Spitzmueller C, et al. Recommendations for using the Revised Safer Dx Instrument to help measure and improve diagnostic safety. Diagnosis (Berl). 2019;6(4):315-323. doi:10.151…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46314/psn-pdf
    November 01, 2020 - AHRQ Safety Program for Improving Antibiotic Use. July 9, 2019 Agency for Healthcare Research and Quality, Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, and University of Chicago. https://psnet.ahrq.gov/issue/ahrq-safety-program-improving-antibiotic-use Improving antibiotic use is a st…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73657/psn-pdf
    September 01, 2021 - Communication failures contributing to patient injury in anaesthesia malpractice claims. September 1, 2021 Douglas RN, Stephens LS, Posner KL, et al. Communication failures contributing to patient injury in anaesthesia malpractice claims. Br J Anaesth. 2021;127(3):470-478. doi:10.1016/j.bja.2021.05.030. https://ps…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43792/psn-pdf
    January 07, 2015 - Patient safety risks associated with telecare: a systematic review and narrative synthesis of the literature. January 7, 2015 Guise V, Anderson JE, Wiig S. Patient safety risks associated with telecare: a systematic review and narrative synthesis of the literature. BMC Health Serv Res. 2014;14:588. doi:10.1186/s129…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48180/psn-pdf
    August 21, 2019 - Burnout and Resilience and Quality and Safety Programs in Obstetrics and Gynecology. August 21, 2019 Main EK, Fowler JM, Gabbe SG, eds. Clin Obstet Gynecol. 2019;62:vii-xii,403-626. https://psnet.ahrq.gov/issue/burnout-and-resilience-and-quality-and-safety-programs-obstetrics-and- gynecology Obstetrics is a high-…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854389/psn-pdf
    October 11, 2023 - Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care. October 11, 2023 Bauer ME, Albright C, Prabhu M, et al. Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care. Obstet Gynecol. 2023;142(3):481-492. doi:10.1097/aog.0000000000005304. https://…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46096/psn-pdf
    May 31, 2017 - Guideline for opioid therapy and chronic noncancer pain. May 31, 2017 Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017;189(18):E659-E666. doi:10.1503/cmaj.170363. https://psnet.ahrq.gov/issue/guideline-opioid-therapy-and-chronic-noncancer-pain Opioid pain…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39277/psn-pdf
    August 22, 2018 - Preventing maternal death. August 22, 2018 Preventing maternal death. Sentinel Event Alert. 2010;44(44):1-4. https://psnet.ahrq.gov/issue/preventing-maternal-death The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adher…
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