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1321. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74713/psn-pdf
      January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking January 26, 2022 Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking Disclosure of Relevant Financial Relationships: As a provider ac…

1322. 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…

1323. Weighing In on Surgical Safety | PSNet
      psnet.ahrq.gov/web-mm/weighing-surgical-safety
      August 04, 2021 - SPOTLIGHT CASE Weighing In on Surgical Safety Citation Text: Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar …

1324. Medication Reconciliation: Whose Job Is It? | PSNet
      psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
      May 01, 2018 - SPOTLIGHT CASE Medication Reconciliation: Whose Job Is It? Citation Text: Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Googl…

1325. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49522/psn-pdf
      November 01, 2006 - Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality November 1, 2006 Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…

1326. Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
      January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx Spotlight Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm…

1327. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863308/psn-pdf
      February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy February 28, 2024 Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy The Case A…

1328. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837660/psn-pdf
      July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse Outcomes July 8, 2022 Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes The Cases Case 1: A 64-year-old man came in for a routine bron…

1329. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49758/psn-pdf
      April 01, 2016 - Dropping to New Lows April 1, 2016 Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/dropping-new-lows Case Objectives State how to manage diabetes medications when patients are admitted to the hospital Describe a guideline-recommended insulin regimen for a hospitaliz…

1330. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33734/psn-pdf
      August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD August 1, 2012 In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd Editor's note: The topic of patient safety in long-term care facilities has not received the attent…

1331. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. | PSNet
      psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
      October 31, 2023 - SPOTLIGHT CASE Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. Citation Text: Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…

1332. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/862983/psn-pdf
      February 28, 2024 - Airway Obstruction during Anterior Cervical Spine Surgery February 28, 2024 Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery The Case A 47-year-old obese man (body weight 13…

1333. Patient Safety in the Ambulatory Care Setting | PSNet
      psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
      April 27, 2022 - Annual Perspective Patient Safety in the Ambulatory Care Setting August 5, 2022  View more articles from the same authors. Citation Text: Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. Rockville (MD): …

1334. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest | PSNet
      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…

1335. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia | PSNet
      psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
      January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia Citation Text: Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…

1336. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy | PSNet
      psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
      March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy Citation Text: Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…

1337. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet
      psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
      September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures Citation Text: Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: …

1338. In Conversation with... Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS | PSNet
      psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
      December 14, 2022 - An emergency need for a surgical procedure could throw off the entire clinic schedule.

1339. Resilient Healthcare and the Safety-I and Safety-II Frameworks | PSNet
      psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
      December 14, 2022 - An emergency need for a surgical procedure could throw off the entire clinic schedule.

1340. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74149/psn-pdf
      January 07, 2022 - Nonetheless, the PCP was quite concerned and scheduled a therapy appointment for the next day, with … leave the ED after an evaluation for suicidal ideation or behavior never attend their first follow-up appointment