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  1. Mobility Lost in the ICU | PSNet

    psnet.ahrq.gov/web-mm/mobility-lost-icu
    August 01, 2018 - SPOTLIGHT CASE Mobility Lost in the ICU Citation Text: Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60542/psn-pdf
    May 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride May 27, 2020 Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride The Case  An infant with trisomy 21 underwent repair of a…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865429/psn-pdf
    April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery April 24, 2024 Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery…

  4. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
    January 01, 2024 - Spotlight Spotlight Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Christian Bohringer, MBBS, …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846126/psn-pdf
    March 09, 2023 - Medication Handling and Compounding Errors in the Operating Room. March 15, 2023 Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room The Case A 62-y…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49564/psn-pdf
    July 01, 2008 - Dependence vs. Pain July 1, 2008 Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dependence-vs-pain Case Objectives Define opioid dependence and opioid withdrawal syndrome. Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid Withdra…

  7. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. | PSNet

    psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
    August 14, 2024 - SPOTLIGHT CASE Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. Citation Text: Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853081/psn-pdf
    August 30, 2023 - In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing August 30, 2023 Sanford K, Schuelke S, Lee M, et al. In Conversation with.. Kathleen Sanford and Sue Schuelke about Virtual Nursing. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schue…

  9. In Conversation With… Dave deBronkart | PSNet

    psnet.ahrq.gov/perspective/conversation-dave-debronkart
    June 01, 2014 - Now we have test strips, meters, and CGMs (continuous glucose monitoring), and as far as I know they

  10. In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles | PSNet

    psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
    August 28, 2024 - exploring protocols for communication channels between clinicians in order to design, develop, and test

  11. Application of Safety-II Principles | PSNet

    psnet.ahrq.gov/perspective/application-safety-ii-principles
    August 28, 2024 - exploring protocols for communication channels between clinicians in order to design, develop, and test

  12. Help & FAQ | PSNet

    psnet.ahrq.gov/information/Faq
    November 01, 2019 - report has a profound impact on understanding and practice, and which the editors believe will stand the test

  13. Patient Advocacy in Patient Safety: Have Things Changed? | PSNet

    psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
    June 01, 2014 - Now we have test strips, meters, and CGMs (continuous glucose monitoring), and as far as I know they

  14. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations | PSNet

    psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
    September 27, 2023 - WebM&M Cases A Postpartum Woman with an Erroneous SARS-CoV-2 Test

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865454/psn-pdf
    March 27, 2024 - Ensuring Patient and Workforce Safety Culture in Healthcare March 27, 2024 Murray J, Sorra J, Gale B, et al. Ensuring Patient and Workforce Safety Culture in Healthcare. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare Introduction In 2020, the I…

  16. Multiple Levels Involved in Prescribing the Wrong Medication | PSNet

    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. Copy Cit…

  17. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet

    psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - SPOTLIGHT CASE Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Citation Text: Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…

  18. Life-Threatening Infant Overdose of Sodium Chloride | PSNet

    psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
    December 23, 2020 - Life-Threatening Infant Overdose of Sodium Chloride Citation Text: Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Form…

  19. In Conversation With… Lawrence Smith, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
    February 01, 2012 - In Conversation With… Lawrence Smith, MD February 1, 2012  Also Read an Essay Citation Text: In Conversation With… Lawrence Smith, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. …

  20. A Loss of Trust and a Missed Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
    October 31, 2023 - SPOTLIGHT CASE A Loss of Trust and a Missed Diagnosis Citation Text: Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format:…
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