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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74713/psn-pdf
    January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking January 26, 2022 Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking Disclosure of Relevant Financial Relationships: As a provider ac…
  2. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
    January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
  3. psnet.ahrq.gov/web-mm/pregnant-danger
    January 12, 2011 - Pregnant With Danger Citation Text: Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
  4. psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
    July 01, 2012 - EMR Entry Error: Not So Benign Citation Text: Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
  5. psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
    April 19, 2023 - In Conversation With… Karl Bilimoria, MD, MS August 1, 2017  Citation Text: In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation …
  6. psnet.ahrq.gov/web-mm/death-pca
    January 06, 2017 - Death by PCA Citation Text: Hicks RW. Death by PCA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…
  7. psnet.ahrq.gov/web-mm/peripheral-iv-too-long
    September 15, 2011 - SPOTLIGHT CASE Peripheral IV in Too Long Citation Text: Fang C-T. Peripheral IV in Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842919/psn-pdf
    February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis. February 1, 2023 Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis The Cases Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
  9. psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
    March 15, 2023 - E-cigarette Explosion in a Patient Room Citation Text: Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…
  10. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
    January 01, 2021 - . – Either SEA was not considered during any of the five visits, or the clinicians did not understand
  11. psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
    July 23, 2024 - In the case of promoting vaginal birth, it is important to understand how C-section rates impact maternal
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837324/psn-pdf
    July 08, 2022 - In the case of promoting vaginal birth, it is important to understand how C-section rates impact maternal
  13. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
    January 01, 2021 - institution may help to validate and implement best practices – Further research is necessary to understand
  14. psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19
    August 31, 2020 - Staff must understand the value of change and innovation and be willing to modify practice to support
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60790/psn-pdf
    February 23, 2022 - the rearview mirror, it is also important that we look beyond treating urgent dental care needs and understand
  16. psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
    May 01, 2012 - That will help us understand the epidemiology of those early harm signals that could be used to identify
  17. psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
    May 01, 2012 - That will help us understand the epidemiology of those early harm signals that could be used to identify
  18. psnet.ahrq.gov/web-mm/delirium-or-dementia
    September 27, 2023 - SPOTLIGHT CASE Delirium or Dementia? Citation Text: Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49750/psn-pdf
    January 01, 2016 - A Room Without Orders January 1, 2016 Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/room-without-orders Case Objectives Review a common process for planned direct hospital admissions. Describe challenges of prioritizing day-to-day patient care activities wi…
  20. Psn-Pdf (pdf file)

    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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