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8941. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73998/psn-pdf
      October 27, 2021 - The Hidden Danger of Unseen Intravenous Catheters October 27, 2021 Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters The Case A 6-week-old infant underwent a craniotomy and excision of abnormal bra…

8942. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49593/psn-pdf
      October 01, 2009 - Who Nose Where the Airway Is? October 1, 2009 Lee CR. Who Nose Where the Airway Is? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/who-nose-where-airway The Case A 70-year-old man with peripheral vascular disease was brought to the operating room to undergo vascular bypass surgery on his right upper extrem…

8943. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.323_slideshow.ppt
      May 01, 2014 - PowerPoint Presentation Spotlight Medication Reconciliation With a Twist (or Dare We Say, a Patch?) This presentation is based on the May 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Janice Kwan, MD, Department of Medicine, University of Tor…

8944. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33886/psn-pdf
      August 01, 2019 - Medical Scribes and Patient Safety August 1, 2019 Woodcock D, Bergstrom R. Medical Scribes and Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety Perspective Scribes have supported physicians for thousands of years.(1) However, little is known about how to…

8945. In Conversation With… Harlan Krumholz, MD, SM | PSNet
      psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
      April 01, 2018 - We never saw them as a tool for communication or as essential to communicating what happened in the hospital

8946. Safety in the Prehospital Emergency Medical Services Setting | PSNet
      psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
      May 01, 2019 - July 24, 2019 Simulation as a tool to improve the safety of pre-hospital anaesthesia—a

8947. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72739/psn-pdf
      February 10, 2021 - Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism February 10, 2021 McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leadi…

8948. Patient Safety and Health Information Technology: Learning from Our Mistakes | PSNet
      psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
      July 01, 2012 - Perspectives on Safety Annual Perspective Technology as a Tool

8949. In Conversation With… David Blumenthal, MD, MPP | PSNet
      psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
      July 01, 2012 - Perspectives on Safety Annual Perspective Technology as a Tool

8950. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836941/psn-pdf
      April 27, 2022 - Post-Acute Transitional Services: Safety in Home-Based Care Programs April 27, 2022 McElroy V, Ordona RB, Bakerjian D. Post-Acute Transitional Services: Safety in Home-Based Care Programs. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs Backgr…

8951. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
      January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx Spotlight The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Source and Credits • This presentation is based on the November 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahr…

8952. In Conversation With… Ashish K. Jha, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
      May 01, 2013 - In Conversation With… Ashish K. Jha, MD, MPH May 1, 2013  Also Read an Essay Citation Text: In Conversation With… Ashish K. Jha, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013…

8953. Patient Safety During Hospital Discharge | PSNet
      psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
      April 01, 2018 - We never saw them as a tool for communication or as essential to communicating what happened in the hospital

8954. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism | PSNet
      psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
      December 31, 2024 - SPOTLIGHT CASE Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism Citation Text: McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…

8955. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33596/psn-pdf
      June 01, 2025 - Failure to Rescue January 29, 2025 Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/failure-rescue Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet primers are regularly reviewed and updated to ensure that they reflect cur…

8956. Caution, Interrupted | PSNet
      psnet.ahrq.gov/web-mm/caution-interrupted
      October 01, 2016 - Caution, Interrupted Citation Text: Wears RL. Caution, Interrupted. 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 R…

8957. The Missing Suction Tip | PSNet
      psnet.ahrq.gov/web-mm/missing-suction-tip
      January 01, 2006 - SPOTLIGHT CASE The Missing Suction Tip Citation Text: Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 …

8958. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73650/psn-pdf
      August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax August 25, 2021 Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…

8959. The Case for Patient Flow Management | PSNet
      psnet.ahrq.gov/web-mm/case-patient-flow-management
      February 23, 2019 - The Case for Patient Flow Management Citation Text: Litvak E, Bernheim SA. The Case for Patient Flow Management. 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 X…

8960. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72618/psn-pdf
      December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care December 23, 2020 https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards- medical-decisions Summary Nudges are a change in the way choices ar…