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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - Good Catch in the Operating Room
Citation Text:
Day J, Paige JT. Good Catch in the Operating Room. 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/web-mm/emergency-error
January 18, 2013 - SPOTLIGHT CASE
Emergency Error
Citation Text:
Symons NRA. Emergency Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous
Combination
April 24, 2024
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous
Combination. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
The Case
A 26-ye…
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psnet.ahrq.gov/node/867985/psn-pdf
January 01, 2025 - Suicide Prevention
March 25, 2025
Boudreaux E, Gale B, Mossburg SE. Suicide Prevention. PSNet [internet]. 20024.
https://psnet.ahrq.gov/perspective/suicide-prevention
Introduction
Suicide is one of the leading causes of death in the United States, accounting for nearly 50,000 deaths in
2022, a 36% rise since 2000…
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
Citation Text:
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
March 01, 2006 - Hyperbilirubinemia Refractory to Phototherapy
Citation Text:
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. 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/node/49567/psn-pdf
September 01, 2008 - Empiric Steroids: the Good, the Bad, and the Ugly
September 1, 2008
Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
Case Objectives
Describe appropriate indications for use of steroids.
Appreciate contraindicati…
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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psnet.ahrq.gov/node/33809/psn-pdf
June 01, 2016 - In Conversation With… Gregg S. Meyer, MD, MSc
June 1, 2016
In Conversation With… Gregg S. Meyer, MD, MSc. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
Editor's note: Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based
system tha…
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psnet.ahrq.gov/node/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
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psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
November 01, 2023 - Inadequate Preanesthetic Evaluation, Airway Trouble
Citation Text:
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. 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/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/issue/nursing-interruptions-trauma-intensive-care-unit-prospective-observational-study
November 09, 2016 - Study
Nursing interruptions in a trauma intensive care unit: a prospective observational study.
Citation Text:
Craker NC, Myers RA, Eid J, et al. Nursing Interruptions in a Trauma Intensive Care Unit: A Prospective Observational Study. J Nurs Adm. 2017;47(4):205-211. doi:10.1097/NNA.0000…
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psnet.ahrq.gov/issue/nature-and-occurrence-registration-errors-emergency-department
September 28, 2016 - Study
The nature and occurrence of registration errors in the emergency department.
Citation Text:
Hakimzada AF, Green RA, Sayan OR, et al. The nature and occurrence of registration errors in the emergency department. Int J Med Inform. 2007;77(3). doi:10.1016/j.ijmedinf.2007.04.011.
…
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psnet.ahrq.gov/issue/understanding-behaviour-newly-qualified-doctors-acute-care-contexts
July 02, 2014 - Study
Understanding the behaviour of newly qualified doctors in acute care contexts.
Citation Text:
Tallentire VR, Smith SE, Skinner J, et al. Understanding the behaviour of newly qualified doctors in acute care contexts. Med Educ. 2011;45(10):995-1005. doi:10.1111/j.1365-2923.2011.040…
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psnet.ahrq.gov/issue/simulation-design-research-evaluating-safety-innovations-anaesthesia
February 25, 2009 - Study
A simulation design for research evaluating safety innovations in anaesthesia.
Citation Text:
Merry AF, Weller JM, Robinson BJ, et al. A simulation design for research evaluating safety innovations in anaesthesia*. Anaesthesia. 2008;63(12):1349-57. doi:10.1111/j.1365-2044.2008.…
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psnet.ahrq.gov/issue/focus-society-cardiovascular-anesthesiologists-initiative-improve-quality-and-safety
January 03, 2017 - Commentary
FOCUS: The Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room.
Citation Text:
Barbeito A, Lau WT, Weitzel N, et al. FOCUS: the Society of Cardiovascular Anesthesiologists' initiative to improve quality and…
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psnet.ahrq.gov/issue/recovery-medical-errors-critical-care-nursing-safety-net
February 18, 2011 - Study
Recovery from medical errors: the critical care nursing safety net.
Citation Text:
Rothschild JM, Hurley A, Landrigan CP, et al. Recovery from medical errors: the critical care nursing safety net. Jt Comm J Qual Patient Saf. 2006;32(2):63-72.
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G…
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psnet.ahrq.gov/issue/state-art-usage-simulation-anesthesia-skills-and-teamwork
June 18, 2014 - Review
State-of-the-art usage of simulation in anesthesia: skills and teamwork.
Citation Text:
Krage R, Erwteman M. State-of-the-art usage of simulation in anesthesia: skills and teamwork. Curr Opin Anaesthesiol. 2015;28(6):727-34. doi:10.1097/ACO.0000000000000257.
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