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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - SPOTLIGHT CASE
Intubation Mishap
Citation Text:
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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April 26, 2023 - In Conversation with... Susan McGrath, PhD and George
Blike, MD about Surveillance Monitoring
April 26, 2023
In Conversation with.. Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-ab…
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - Complications of ECMO During Transport
Citation Text:
Broman M. Complications of ECMO During Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication
Citation Text:
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement
Carole Stockmeier, Sarah Mossburg, Lee Merton | September 24, 2024
Also Read the Essay
View more articles from the same authors.
…
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psnet.ahrq.gov/web-mm/citrate-mix
February 01, 2010 - Citrate Mix-Up
Citation Text:
Weber RJ. Citrate Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/web-mm/forgotten-drip
April 01, 2014 - The Forgotten Drip
Citation Text:
Josephson AS. The Forgotten Drip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/insert-omission
May 09, 2014 - Insert Omission
Citation Text:
Darney P. Insert Omission. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/33689/psn-pdf
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary,
Promoter of Patient Safety
October 1, 2009
Wachter R. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety. PSNet [internet].
2009.
https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
Perspective
…
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psnet.ahrq.gov/node/33821/psn-pdf
December 01, 2016 - Errors and Near Misses: What Health Care Could Learn
From Aviation
December 1, 2016
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
Perspective
Some of the most urg…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
May 01, 2012 - Spotlight Case July 2008
Spotlight Case
The Perils of Cross Coverage
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Source and Credits
This presentation is based on the May 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …
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psnet.ahrq.gov/node/49812/psn-pdf
November 01, 2017 - Specimen Almost Lost
November 1, 2017
Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/specimen-almost-lost
The Case
A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen.
She was admitted to the medicine service for further evalu…
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
January 01, 2020 - PowerPoint Presentation
Spotlight
A ʺReflexiveʺ Diagnosis in Primary Care
1
This presentation is based on the April 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John Betjemann, MD, and S. Andrew Josephson, MD, University of California, San…
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psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - Amphotericin Toxicity
October 1, 2015
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/amphotericin-toxicity
The Case
A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral
posaconazole for residual fungal disease. She present…
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psnet.ahrq.gov/node/49740/psn-pdf
August 21, 2015 - Baffled by Botulinum Toxin
August 21, 2015
Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
The Case
A 5-year-old boy with a history of transverse myelitis with resultant spasticity of both lower extremities, gait
abnormalities, neurogeni…
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psnet.ahrq.gov/node/49463/psn-pdf
October 14, 2004 - Moved Too Soon
October 1, 2004
Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/moved-too-soon
The Case
A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours
after arriving, while the patient was still groggy from anesthesia, a nurs…
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psnet.ahrq.gov/node/33640/psn-pdf
September 01, 2006 - What Can the Rest of the Health Care System Learn from
the VA's Quality and Safety Transformation?
September 1, 2006
Jha AK. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety
Transformation? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system…
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psnet.ahrq.gov/node/33835/psn-pdf
June 01, 2017 - In Conversation With… Paul Aylin, MBChB
June 1, 2017
In Conversation With… Paul Aylin, MBChB. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
Editor's note: Professor Aylin is Professor of Epidemiology and Public Health at Imperial College London,
where he is also Co-Direc…