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8681. No News May Not Be Good News | PSNet
      psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
      December 07, 2009 - SPOTLIGHT CASE No News May Not Be Good News Citation Text: Moore CR. No News May Not Be Good News. 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 X…

8682. SNFs: Opening the Black Box | PSNet
      psnet.ahrq.gov/web-mm/snfs-opening-black-box
      August 27, 2012 - SNFs: Opening the Black Box Citation Text: Ouslander JG, Bonner A. SNFs: Opening the Black Box. 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 X…

8683. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846170/psn-pdf
      March 15, 2023 - Duplicate Therapies in Retail Pharmacy March 15, 2023 Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy The Cases Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection f…

8684. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50611/psn-pdf
      October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing October 30, 2019 Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing Case Objectives List the most common errors associated with computerized…

8685. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73642/psn-pdf
      August 25, 2021 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected August 25, 2021 Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect- unexpected …

8686. Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
      January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx Spotlight Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm…

8687. U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument | PSNet
      psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
      February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL January …

8688. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74691/psn-pdf
      January 01, 2021 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument January 26, 2022 https://psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor- college-medicine Summary The Revised Safer Dx Instr…

8689. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49624/psn-pdf
      May 01, 2011 - Duty to Disclose Someone Else's Error? May 1, 2011 Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error Case Objectives State the rationale for disclosing medical errors. Describe key principles in effective error disclosure. …

8690. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865411/psn-pdf
      March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy March 27, 2024 Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…

8691. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33732/psn-pdf
      July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP July 1, 2012 In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp Editor's note: David Blumenthal, MD, MPP, is Chief Health Information and Innovation Officer, Partners Healt…

8692. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73336/psn-pdf
      May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers May 26, 2021 Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers The Case  …

8693. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49684/psn-pdf
      May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical Error May 1, 2013 Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error Case Objectives Appreciate that chemotherapy a…

8694. Radiology Missed an Intracranial Bleed in a Lethargic Infant. | PSNet
      psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
      August 21, 2016 - Radiology Missed an Intracranial Bleed in a Lethargic Infant. Citation Text: Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation For…

8695. Failure to Report | PSNet
      psnet.ahrq.gov/web-mm/failure-report
      July 01, 2008 - SPOTLIGHT CASE Failure to Report Citation Text: Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…

8696. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865296/psn-pdf
      March 27, 2024 - National Patient Safety Goals March 27, 2024 Shaikh U. National Patient Safety Goals. PSNet [internet]. 2024. https://psnet.ahrq.gov/primer/national-patient-safety-goals Background Despite the development and publication of effective and evidence-based strategies to enhance patient safety and reduce preventable h…

8697. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.2_slideshow.ppt
      February 01, 2003 - PowerPoint Presentation Spotlight Case February 2003 Apnea in a Patient Under General Anesthesia webmm.ahrq.gov Source and Credits This presentation is based on February 2003 Surgery–Anesthesia Spotlight Case See full case–commentary on webmm.ahrq.gov CME credit is available online Commentary by: Paul Barach,…

8698. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867676/psn-pdf
      February 26, 2025 - Responding to Patient Safety Events February 26, 2025 Shaikh U. Responding to Patient Safety Events. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/responding-patient-safety-events Background Patient safety events that occur in health care facilities require prompt action to ensure that further harm is mit…

8699. Culture of Safety | PSNet
      psnet.ahrq.gov/primer/culture-safety
      September 15, 2024 - Culture of Safety Citation Text: Culture of Safety. 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 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

8700. Identifying Adverse Events Not Present on Admission: Can We Do It? | PSNet
      psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
      October 01, 2008 - Identifying Adverse Events Not Present on Admission: Can We Do It? James M. Naessens, ScD | October 1, 2008  Also Read a Conversation View more articles from the same authors. Citation Text: Naessens JM. Identifying Adverse Events Not Present on Admission: Can W…