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psnet.ahrq.gov/issue/adopting-national-quality-forum-medication-safe-practices-progress-and-barriers-hospital
December 16, 2011 - January 28, 2010
10 Patient Safety Tips for Hospitals.
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psnet.ahrq.gov/node/851099/psn-pdf
June 28, 2023 - Misconnection Leading to Arterial Thrombosis
June 28, 2023
Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
The Case
A 55-year-old man with chronic obstructive pulmonary disease (COPD) was brought by am…
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - SPOTLIGHT CASE
The Wet Read
Citation Text:
Arenson RL. The Wet Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
January 01, 2022 - Spotlight
Spotlight
Fecal Contamination of the Peritoneum from
Laparoscopic Trocar Injury: A Routine
Operation Goes Wrong
Source and Credits
• This presentation is based on the October 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary…
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psnet.ahrq.gov/node/838900/psn-pdf
October 27, 2022 - Fecal Contamination of the Peritoneum from
Laparoscopic Trocar Injury: A Routine Operation Goes
Wrong.
October 27, 2022
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine
Operation Goes Wrong. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/fecal-contamination-…
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psnet.ahrq.gov/node/33706/psn-pdf
February 01, 2011 - In Conversation with...Brent C. James, MD, MStat
February 1, 2011
In Conversation with..Brent C. James, MD, MStat. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
Editor's note: Brent C. James, MD, MStat, is Chief Quality Officer and Executive Director of the Insti…
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - Airway Obstruction during Anterior Cervical Spine Surgery
Citation Text:
Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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…
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psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
March 24, 2019 - Hypoxemia after Emergency Intubation
Citation Text:
Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
Google Scholar BibTeX EndNote X3 X…
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psnet.ahrq.gov/node/867357/psn-pdf
December 18, 2024 - Hypoxemia after Emergency Intubation
December 18, 2024
Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
The Case
A 19-month-old child was brought to the emergency department (ED) via ambulance after drowning in a
p…
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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - multiple parts, and may include but are not limited to electrosurgical scratch pads, electrocautery tips
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psnet.ahrq.gov/issue/letter-health-care-providers-safe-use-surgical-staplers-and-staples
October 20, 2021 - Press Release/Announcement
Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples.
Citation Text:
Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples. US Food and Drug Administration. October 7, 2021.
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S…
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psnet.ahrq.gov/issue/cardinal-health-recalls-argyle-uvc-insertion-tray-due-missing-instructions-use-safety-scalpel
August 20, 2021 - Press Release/Announcement
Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11.
Citation Text:
Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11. MedWatch Safety Al…
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psnet.ahrq.gov/web-mm/mark-my-limb
February 10, 2015 - Mark My Limb
Citation Text:
Jacott WE, O'Leary D. Mark My Limb. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49410/psn-pdf
July 01, 2003 - A Little Shuteye
July 1, 2003
Farion KJ. A Little Shuteye. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/little-shuteye
The Case
A 3-year-old boy was seen in urgent care for a superficial laceration above the left eyebrow. The
pediatrician had heard of the availability of topical skin adhesive that can be…
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psnet.ahrq.gov/node/49421/psn-pdf
October 01, 2003 - Urine a Tough Position
October 1, 2003
Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/urine-tough-position
The Case
A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although
she did not want to have a baby at that time, she sta…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.14_slideshow.ppt
May 01, 2003 - PowerPoint Presentation
Spotlight Case May 2003
Central Line Complications in an Infant
webmm.ahrq.gov
Source and Credits
This presentation is based on the May 2003
AHRQ WebM&M Spotlight Case in Pediatrics
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary…
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psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
February 26, 2025 - In Conversation with...Brent C. James, MD, MStat
February 1, 2011
Citation Text:
In Conversation with..Brent C. James, MD, MStat. PSNet [internet]. 2011.In Conversation with...Brent C. James, MD, MStat. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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psnet.ahrq.gov/issue/relationship-between-hospital-systems-load-and-patient-harm
November 12, 2008 - Study
The relationship between hospital systems load and patient harm.
Citation Text:
Pedroja AT, Blegen MA, Abravanel R, et al. The relationship between hospital systems load and patient harm. J Patient Saf. 2014;10(3):168-75. doi:10.1097/PTS.0b013e31829e4f82.
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Format…
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psnet.ahrq.gov/node/49389/psn-pdf
February 01, 2003 - Procedural Mishap: Learning Curve?
February 1, 2003
Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
The Case
A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had
undesired fert…
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psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization
Citation Text:
Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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