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  1. Isolated Clot, Real Error | PSNet

    psnet.ahrq.gov/web-mm/isolated-clot-real-error
    December 01, 2013 - SPOTLIGHT CASE Isolated Clot, Real Error Citation Text: Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  2. Suicidal Ideation in the Family Medicine Clinic | PSNet

    psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
    October 01, 2007 - SPOTLIGHT CASE Suicidal Ideation in the Family Medicine Clinic Citation Text: Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: …

  3. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet

    psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
    August 01, 2009 - Misplaced Nasogastric Tube Resulting in Aspiration Citation Text: Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google S…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49801/psn-pdf
    August 01, 2017 - Despite Clues, Failed to Rescue August 1, 2017 Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue Case Objectives Define failure to rescue. Identify the main contributors to failure-to-rescue events. Appreciate the ongoing areas of scien…

  5. Critical Echocardiogram Result Lost to Follow-up | PSNet

    psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
    July 31, 2023 - Critical Echocardiogram Result Lost to Follow-up Citation Text: Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Sch…

  6. 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…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60328/psn-pdf
    May 27, 2020 - Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression May 27, 2020 Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory- …

  8. Intubation Mishap | PSNet

    psnet.ahrq.gov/web-mm/intubation-mishap
    April 26, 2023 - SPOTLIGHT CASE Intubation Mishap Citation Text: Weinger MB, Blike G. Intubation Mishap. 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 XML EndNote …

  9. Safety Across The Board | PSNet

    psnet.ahrq.gov/perspective/safety-across-board
    August 31, 2020 - Safety Across The Board August 31, 2020  Also Read the Conversation View more articles from the same authors. Citation Text: Fitall E, Hall KK, Gale B. Safety Across The Board . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…

  10. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes | PSNet

    psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
    April 10, 2024 - Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes Citation Text: Bakerjian D. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health…

  11. Patient Safety Amid Nursing Workforce Challenges | PSNet

    psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
    April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD | April 24, 2024  Also Read the Conversation View more articles from the same authors. Citation Text: Leary KB, L…

  12. In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges | PSNet

    psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
    April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT | April 24, 2024  Also Read the Essay View more articles from the same authors. Citation Text: Leary KB. In Con…

  13. Despite Clues, Failed to Rescue | PSNet

    psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
    August 02, 2015 - SPOTLIGHT CASE Despite Clues, Failed to Rescue Citation Text: Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndN…

  14. What Happened on Telemetry? | PSNet

    psnet.ahrq.gov/web-mm/what-happened-telemetry
    January 18, 2012 - SPOTLIGHT CASE What Happened on Telemetry? Citation Text: Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNo…

  15. Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up | PSNet

    psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
    September 27, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up Citation Text: Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…

  16. Delayed Evaluation of Abdominal Pain in an Elderly Patient. | PSNet

    psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
    February 26, 2020 - Delayed Evaluation of Abdominal Pain in an Elderly Patient. Citation Text: Klimkiv L, Utter GH, Barnes DK. Delayed Evaluation of Abdominal Pain in an Elderly Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citat…

  17. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. | PSNet

    psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
    June 24, 2020 - SPOTLIGHT CASE Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. Citation Text: Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…

  18. A Postpartum Woman with an Erroneous SARS-CoV-2 Test | PSNet

    psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
    December 23, 2020 - A Postpartum Woman with an Erroneous SARS-CoV-2 Test Citation Text: Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Forma…

  19. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression | PSNet

    psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
    May 26, 2021 - SPOTLIGHT CASE Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression Citation Text: Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…

  20. Safety Culture in EMS | PSNet

    psnet.ahrq.gov/perspective/safety-culture-ems
    May 26, 2021 - Safety Culture in EMS May 26, 2021  Also Read the Conversation View more articles from the same authors. Citation Text: Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US…
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