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psnet.ahrq.gov/node/50931/psn-pdf
February 26, 2020 - Timely diagnosis of esophageal perforation
February 26, 2020
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
The Case
A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…
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psnet.ahrq.gov/node/866621/psn-pdf
August 28, 2024 - Application of Safety-II Principles
August 28, 2024
Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/application-safety-ii-principles
Traditional approaches to patient safety have often been reactive rather than proactive, seeki…
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psnet.ahrq.gov/node/33778/psn-pdf
March 01, 2015 - Diagnostic Errors
January 1, 2014
Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/diagnostic-errors
Annual Perspective 2014
Until very recently, diagnostic errors received relatively little attention in the field of patient safety,
particularly when compared wi…
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psnet.ahrq.gov/node/49488/psn-pdf
August 21, 2005 - PCA Overdose
August 21, 2005
Doyle JD. PCA Overdose. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pca-overdose
The Case
A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo-
oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.287_slideshow.ppt
December 01, 2012 - Spotlight Case July 2008
Spotlight Case
The Lung Nodule That Refused To Grow
*
*
Source and Credits
This presentation is based on the December 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Alex A. Balekian, MD, MSHS, Keck School of Med…
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psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Check the Anesthesia Machine
December 1, 2013
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/check-anesthesia-machine
The Case
A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension,
diabetes, sleep apnea…
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psnet.ahrq.gov/glossary
January 01, 2003 - pneumothorax from central venous catheter placement counts as an adverse event regardless of insertion technique … Cooper and colleagues brought the technique of critical incident analysis to a wide audience in health … care but followed the definition of the originator of the technique. … However, the reliability of the technique is not clear .
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psnet.ahrq.gov/glossary-0
January 01, 2003 - pneumothorax from central venous catheter placement counts as an adverse event regardless of insertion technique … Cooper and colleagues brought the technique of critical incident analysis to a wide audience in health … care but followed the definition of the originator of the technique. … However, the reliability of the technique is not clear .
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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - In the setting of an obese patient who has vomited, two hand mask ventilation technique is likely needed
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique
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psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
December 01, 2012 - In this case, the ultrasound report would state the indication for the examination, the technique, the
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psnet.ahrq.gov/node/862983/psn-pdf
February 28, 2024 - table.4 As highlighted in a previous WebM&M commentary, using a video-
laryngoscope is the intubation technique
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psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
February 26, 2025 - Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - Additionally, insulin pump infusion site leakage occurred several times, possibly due to improper insertion technique
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique
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psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
August 31, 2022 - debriding an NSTI, but the key skills for successful management of NSTIs involve surgical judgment , not technique
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psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - Postoperative temporomandibular joint dislocation reduced by the syringe
technique.
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psnet.ahrq.gov/node/33766/psn-pdf
May 01, 2014 - patients should have the right to benefit from health
care workers practicing appropriate hand hygiene technique
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psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
December 01, 2014 - insertion.( 9 ) Additionally, the risk of procedure-associated injury is significantly reduced using this technique