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psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - cannot lie flat for the operation while breathing spontaneously, as is required for the ophthalmic surgeon
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - A cardiovascular surgeon was consulted that day, and bypass surgery was scheduled for 4 days later.
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psnet.ahrq.gov/node/33838/psn-pdf
July 01, 2017 - Doctors With Multiple Malpractice Claims, Disciplinary
Actions, and Complaints: What Do We Know?
July 1, 2017
Studdert DM. Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We
Know? PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-…
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psnet.ahrq.gov/node/49796/psn-pdf
June 01, 2017 - Chest Tube Complications
June 1, 2017
Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/chest-tube-complications
The Case
A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for management of a
spontaneous left pneumothorax (coll…
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psnet.ahrq.gov/web-mm/did-we-forget-something
April 28, 2021 - Did We Forget Something?
Citation Text:
Gibbs VC. Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/node/49572/psn-pdf
October 01, 2008 - Mistaken Identity
October 1, 2008
Hall LW. Mistaken Identity. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mistaken-identity
The Case
An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status
and a reported fall. After finding tenderness in her left hip, the p…
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psnet.ahrq.gov/node/49589/psn-pdf
August 01, 2009 - Hiding in Plain Sight
August 1, 2009
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/hiding-plain-sight
The Case
A 65-year-old woman presented to an emergency department (ED) with 48 hours of nontraumatic left lower
back pain and general malaise. She was diagnosed with a …
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psnet.ahrq.gov/web-mm/one-ace-too-many
June 21, 2016 - One ACE Too Many
Citation Text:
Juurlink DN. One ACE Too Many. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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…
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psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - initiatives and other areas of healthcare, could be a significant downside to pursuing zero harm, argues surgeon
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - I know a hospital where the biggest trauma surgeon in the region had his
privileges to do surgery and
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Crisis
March 15, 2023
WebM&M Cases
Think Like a Surgeon
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - An orthopedic surgeon was consulted and recommended closed reduction of
the left hip in the ED. … The orthopedic surgeon performed the hip reduction successfully.
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psnet.ahrq.gov/node/852698/psn-pdf
August 30, 2023 - collaboration with oncology leaders,
and conducted by a team of oncologists, a pathologist, and an oncologic surgeon
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psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
March 15, 2023 - August 19, 2020
Multisource evaluation of surgeon behavior is associated with malpractice
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - and Treatment Leading to Death from Pulmonary Embolism
February 10, 2021
Surgeon
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psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - )
WebM&M Cases
Diagnosing HIV-It Doesn't Take a Brain Surgeon
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - He was seen by an orthopedic surgeon and was admitted for
treatment of infection and hyperglycemia.
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psnet.ahrq.gov/Information/Editor
May 23, 2025 - He joined the UC Davis faculty in 2005 and has remained clinically active as a trauma and acute care surgeon
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - August 14, 2024
Surgeon and surgical trainee experiences after adverse patient events
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psnet.ahrq.gov/node/72564/psn-pdf
November 14, 2018 - Antibiotic and Opioid Stewardship in Dentistry
December 7, 2020
Suda KJ, Fitall E, Hall KK, et al. Antibiotic and Opioid Stewardship in Dentistry. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry
Introduction
Medication stewardship refers to efforts by frontlin…