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psnet.ahrq.gov/node/33861/psn-pdf
July 01, 2018 - The thoracic surgeon said
I "shouldn't fall on my sword" because the delay didn't really change her stage
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - the morning after her cesarean section, the finding was attributed to having pushed during the second stage
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psnet.ahrq.gov/perspective/conversation-lucian-leape-md
June 12, 2019 - RW : At this stage now in the safety field, what do you see that gives you hope?
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - The thoracic surgeon said I "shouldn't fall on my sword" because the delay didn't really change her stage
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psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
March 01, 2015 - process control methods ( 19 ) to flag unfavorable trends in diagnosis-specific mortality at an early stage
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psnet.ahrq.gov/node/857061/psn-pdf
November 27, 2023 - The faculty member
is usually on the “stage,” and they impart the knowledge and information to the student
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psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
February 26, 2025 - training and measurement programs without addressing the burnout, or do you think this is an inevitable stage
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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…
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psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
November 25, 2020 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Intubation Mishap
September 1, 2003
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/intubation-mishap
Case Objectives
To understand and apply a structured method of human factors case analysis
To describe the key components of effective teamwork
To understand the imp…
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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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,…
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psnet.ahrq.gov/node/867022/psn-pdf
October 30, 2024 - Delayed Symptomatic Subdural Hematoma Following an
Initially Normal CT Head
October 30, 2024
Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-h…
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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…
-
psnet.ahrq.gov/node/867805/psn-pdf
February 26, 2025 - In Conversation with David W. Bates about Are We Safer
Today?
February 26, 2025
Bates DW, Lee M, Mossburg SE. In Conversation with David W. Bates about Are We Safer Today? PSNet
[internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
Editor’s note: David W. Bates, …
-
psnet.ahrq.gov/node/33789/psn-pdf
August 01, 2015 - In Conversation With… Robert M. Wachter, MD
August 1, 2015
In Conversation With… Robert M. Wachter, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
Editor's note: Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF,
where he also …
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - Case 2: A 78-year-old woman with a history of obesity, diabetes mellitus, anemia, anxiety, end-stage
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - language disturbances, such as frank aphasia, can result from migraine.( 15 ) So even in the first stage
-
psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - The Case
A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted
-
psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - adolescents include the following: non-white, non-European descent; age older than 10 years; Tanner stage