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5661. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50768/psn-pdf
      December 27, 2019 - In Conversation With... Cindy Brach December 27, 2019 In Conversation With.. Cindy Brach. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-cindy-brach Editor’s note: Cindy Brach, MPP is a Senior Healthcare Researcher at the Agency for Healthcare Research and Quality and is the Co-Chair of th…

5662. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49731/psn-pdf
      April 01, 2015 - Fire in the Hole!—An OR Fire April 1, 2015 Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fire-hole-or-fire The Case A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinom…

5663. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49592/psn-pdf
      October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…

5664. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73335/psn-pdf
      May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …

5665. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72693/psn-pdf
      January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…

5666. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
      July 01, 2012 - Spotlight Case July 2008 Spotlight Case Not-So-Therapeutic Tap * * Source and Credits This presentation is based on the July 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jeffrey H. Barsuk, MD, MS; Northwestern University Feinberg Scho…

5667. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49538/psn-pdf
      June 01, 2007 - Abnormal Volunteer Results June 1, 2007 Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results The Case A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent magnetic resonance imaging (MRI) of her abdo…

5668. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33632/psn-pdf
      April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD (hon) April 1, 2006 In Conversation with… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background and how…

5669. Over Not So Easy | PSNet
      psnet.ahrq.gov/web-mm/over-not-so-easy
      April 01, 2005 - Over Not So Easy Citation Text: Cucina R. Over Not So Easy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

5670. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73999/psn-pdf
      October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room October 27, 2021 Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room …

5671. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49401/psn-pdf
      May 01, 2003 - Suicidal Man With Gun May 1, 2003 Simon RI. Suicidal Man With Gun. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/suicidal-man-gun The Case The patient is a 36-year-old man who came to a psychiatry clinic for outpatient evaluation of severe depression that had persisted for nearly 2 years. On initial inter…

5672. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49466/psn-pdf
      October 14, 2004 - Hard to Swallow October 1, 2004 Driver J. Hard to Swallow. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/hard-swallow The Case An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, …

5673. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49637/psn-pdf
      October 01, 2011 - The Dropped "No" October 1, 2011 Johnson AJ. The Dropped "No". PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropped-no The Case A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in his legs. Because the leg swelling was somewhat more pronounced in his…

5674. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49815/psn-pdf
      December 01, 2017 - Over-the-Counter Oversight December 1, 2017 Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/over-counter-oversight The Case A 56-year-old man was evaluated in the burn clinic for a second-degree burn on his chest. Although portions of his skin we…

5675. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49423/psn-pdf
      November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…

5676. Telehealth and Patient Safety. | PSNet
      psnet.ahrq.gov/primer/telehealth-and-patient-safety
      July 27, 2022 - Telehealth and Patient Safety. Citation Text: O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndNote X3 …

5677. Dangerous Dapsone | PSNet
      psnet.ahrq.gov/web-mm/dangerous-dapsone
      January 10, 2011 - Dangerous Dapsone Citation Text: Bookwalter T. Dangerous Dapsone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…

5678. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33762/psn-pdf
      March 01, 2014 - In Conversation With… Alison Holmes, MD, MPH March 1, 2014 In Conversation With… Alison Holmes, MD, MPH. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph Editor's note: Dr. Alison Holmes is Director of Infection Prevention and Control at Imperial College Healthcare NHS …

5679. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49718/psn-pdf
      January 01, 2015 - Too Much, Too Fast September 1, 2014 Tuot D. Too Much, Too Fast. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/too-much-too-fast The Case A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for fever, tachycardia, and increased respiratory secretions. H…

5680. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49625/psn-pdf
      May 01, 2011 - Pocket Syringe Swap May 1, 2011 Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/pocket-syringe-swap The Case A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for postoperative pain management. Surgery proceeded uneventfully under…