-
psnet.ahrq.gov/web-mm/dont-pick-picc
December 01, 2011 - Dialysis access planning was initiated, but unfortunately, when the patient was evaluated by a vascular surgeon
-
psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
February 10, 2010 - One month later, the patient returned for a second evaluation under anesthesia, and the surgeon noted
-
psnet.ahrq.gov/web-mm/environmental-safety-or
May 19, 2015 - One cardiac surgeon and his team were identified as having higher infection rates than others, even though
-
psnet.ahrq.gov/periodic-issue/periodic-issue-427
February 28, 2024 - The Black Belt cervical retractor was released by the surgeon resulting in complete resolution of the
-
psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
November 25, 2020 - In the operating room, the surgeon found stercoral colitis and a large perforated “stercoral ulcer” of
-
psnet.ahrq.gov/web-mm/new-oral-anticoagulants
July 01, 2011 - appropriately held before her surgery and then restarted on the second hospital day, presumably when the surgeon
-
psnet.ahrq.gov/node/846768/psn-pdf
March 29, 2023 - cannot lie flat for the
operation while breathing spontaneously, as is required for the ophthalmic surgeon
-
psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - complicated than he or she can manage
Nursing or physician staff, or the patient request that the attending surgeon … December 18, 2014
Multisource evaluation of surgeon behavior is associated with malpractice
-
psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 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.
7
Case Details (4)
• The
-
psnet.ahrq.gov/web-mm/overdose-oxygen
August 02, 2023 - Overdose on Oxygen?
Citation Text:
O'Driscoll RB. Overdose on Oxygen?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
-
psnet.ahrq.gov/node/60220/psn-pdf
April 29, 2020 - Implicit Biases, Interprofessional Communication, and
Power Dynamics
April 29, 2020
Sanchez ES, Tran-Reina M, Ackerman-Barger K, et al. Implicit Biases, Interprofessional Communication,
and Power Dynamics. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/implicit-biases-interprofessional-communication-and-pow…
-
psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - The surgeon had already destroyed two of these devices, and there was only one left in the whole OR suite
-
psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - In Conversation With… Vineet Chopra, MD, MSc
October 30, 2019
Citation Text:
In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation…
-
psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health
Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for
Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…
-
psnet.ahrq.gov/issue/preventing-workplace-violence
July 25, 2023 - International Meeting/Conference
Preventing Workplace Violence.
Citation Text:
National Action Alliance. June 27, 2023. 2:00- 3:00 PM (eastern)
Copy Citation
Save
Save to your library
Print
Share
Facebook
Twitter
Linkedin
Copy UR…
-
psnet.ahrq.gov/issue/optimizing-medication-reconciliation-and-transitions-care-insights-pharmacist-and-pharmacy
July 25, 2023 - International Meeting/Conference
Optimizing Medication Reconciliation and Transitions of Care: Insights from a Pharmacist and Pharmacy Technician.
Citation Text:
Health Quality Institute. July 12, 2023, 2:00-3:00 PM (eastern).
Copy Citation
Save
Save to your lib…
-
psnet.ahrq.gov/issue/judy-smetzer-just-culture-champion-scholarships
April 18, 2012 - Press Release/Announcement
Judy Smetzer Just Culture Champion Scholarships.
Citation Text:
Institute for Safe Medication Practices.
Copy Citation
Save
Save to your library
Print
Share
Facebook
Twitter
Linkedin
Copy URL
…
-
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.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
-
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 …
-
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-…