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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - Pocket Syringe Swap
Citation Text:
Kulli JC. Pocket Syringe Swap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
October 01, 2017 - Preventing PICC Complications: Whose Line Is It?
Citation Text:
Moureau N. Preventing PICC Complications: Whose Line Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/dressed-failure
September 01, 2011 - DRESSed for Failure
Citation Text:
Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
June 07, 2023 - Breathe Easy: Safe Tracheostomy Management
Citation Text:
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room
Citation Text:
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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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.
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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.
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psnet.ahrq.gov/node/33717/psn-pdf
September 01, 2011 - Incident Reporting: More Attention to the Safety Action
Feedback Loop, Please
September 1, 2011
Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet
[internet]. 2011.
https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
…
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - Medical Devices in the "Wild"
Citation Text:
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/49411/psn-pdf
July 01, 2003 - Code Status Confusion
July 1, 2003
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/code-status-confusion
Case Objectives
Appreciate challenges of determining goals of care in hospitalized patients
Understand patients’ common misconceptions about CPR
List typical mist…
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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac
Arrest
September 30, 2020
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
Disclosure of Relevant Financial Relationships: As a pr…
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psnet.ahrq.gov/node/49677/psn-pdf
February 01, 2013 - CVC Placement: Speak Now or Do Not Use the Line
February 1, 2013
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
The Case
A 48-year-old woman with a history of hypertension, psychiatric illness, and a…
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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - The Case of Mistaken Intubation
June 1, 2016
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/case-mistaken-intubation
Case Objectives
Appreciate that most older adults and many younger chronically ill patients have discussed or
documented their preferences for l…
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psnet.ahrq.gov/node/33758/psn-pdf
December 01, 2013 - In Conversation With… Hardeep Singh, MD, MPH
December 1, 2013
In Conversation With… Hardeep Singh, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
Editor's note: Hardeep Singh, MD, MPH, is Chief of the Health Policy, Quality and Informatics Program at
the Hous…
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psnet.ahrq.gov/node/49787/psn-pdf
March 01, 2017 - Diagnosing a Missed Diagnosis
March 1, 2017
Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
The Case
A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and
disorientation. She was taking mod…
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psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
August 21, 2007 - SPOTLIGHT CASE
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
Citation Text:
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Huma…
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psnet.ahrq.gov/node/33614/psn-pdf
June 01, 2005 - Interpreting the Patient Safety Literature
June 1, 2005
Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
Perspective
Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - Add-on Case and the Missing Checklist
Citation Text:
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/preventable-transfer-hospital
March 31, 2022 - Preventable Transfer to the Hospital
Citation Text:
Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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