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1641. Good Catch in the Operating Room | PSNet
      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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

1642. Inadequate Preanesthetic Evaluation, Airway Trouble | PSNet
      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. Copy Citation Format: Google Scholar …

1643. Clostridium Difficile Relapse Secondary to Medication Access Issue | PSNet
      psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
      October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue Citation Text: Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Cit…

1644. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865778/psn-pdf
      May 29, 2024 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement May 29, 2024 Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-complications-unint…

1645. Psn-Pdf (pdf file)
      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…

1646. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49779/psn-pdf
      January 01, 2017 - The Empty Bag December 1, 2016 Vincent C. The Empty Bag. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/empty-bag The Case A 90-year-old woman with end-stage dementia was admitted to an acute care hospital for treatment of a hip fracture after a fall at a nursing home. During the hospitalization, her kidne…

1647. In Conversation With... James P. Bagian, MD, PE | PSNet
      psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
      February 26, 2025 - In Conversation With... James P. Bagian, MD, PE December 1, 2016  Citation Text: In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016.In Conversation With... James P. Bagian, MD, PE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research a…

1648. In Conversation with...Albert Wu, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
      February 26, 2025 - In Conversation with...Albert Wu, MD, MPH July 1, 2008  Citation Text: In Conversation with..Albert Wu, MD, MPH. PSNet [internet]. 2008.In Conversation with...Albert Wu, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…

1649. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49865/psn-pdf
      June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy June 1, 2019 Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy The Case A 75-year-old man with a past medical history of hemorrhagic stroke, coron…

1650. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
      May 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer? * * Source and Credits This presentation is based on the May 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Sidney W.A. Dekker, Ph…

1651. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861838/psn-pdf
      January 31, 2024 - Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling January 31, 2024 https://psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling Summary Adverse events resulting from medications are a common occurrence that often go undetected, unreported, and unaddressed.1 The imp…

1652. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
      November 01, 2005 - senior leadership support Secure commitment for resources for the project during its development Start

1653. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33649/psn-pdf
      May 01, 2007 - And I did start to challenge these doctors' colleagues, who were usually protecting their associates … Then we can start to highlight areas where things are getting better.

1654. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73229/psn-pdf
      May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities May 26, 2021 Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…

1655. Antiseizure Medication Disorder | PSNet
      psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
      April 01, 2006 - SPOTLIGHT CASE Antiseizure Medication Disorder Citation Text: Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX En…

1656. July Syndrome | PSNet
      psnet.ahrq.gov/web-mm/july-syndrome
      July 01, 2011 - various members of the interprofessional team during the transition, and the implementation of staggered start

1657. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33806/psn-pdf
      April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH April 1, 2016 In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of Pediatrics a…

1658. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49732/psn-pdf
      May 01, 2015 - Errors in Sepsis Management May 1, 2015 Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/errors-sepsis-management Case Objectives Define sepsis, severe sepsis, and septic shock. Describe the severe sepsis/septic shock resuscitation bundle. Recognize commonly encou…

1659. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49571/psn-pdf
      October 01, 2008 - Coming Up Short October 1, 2008 Hochberg Z'ev. Coming Up Short. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/coming-short The Case A 12-year-old Hispanic female was seen for a well-child check. The child was delivered 2 months prematurely (likely due to domestic violence) in Puerto Rico. She had an intra…

1660. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33642/psn-pdf
      November 01, 2006 - In Conversation With...Donald A. Norman, PhD November 1, 2006 In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you become interested…