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Spotlight Case July 2008 (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.pptOctober 01, 2010 - Spotlight Case July 2008 Spotlight Case October 2010 Dangerous Dialysis * * Source and Credits This presentation is based on the October 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866847/psn-pdfSeptember 25, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 25, 2024 Stockmeier CA, Mossburg S, Lee M. In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Are… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50931/psn-pdfFebruary 26, 2020 - Timely diagnosis of esophageal perforation February 26, 2020 Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation The Case A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73387/psn-pdfMarch 17, 2021 - COVID-19 and the Built Environment June 30, 2021 Joseph A, Scanlon MM, Fitall E, et al. COVID-19 and the Built Environment. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/covid-19-and-built-environment Introduction The “built environment” in healthcare refers to the hospital structure and any other fix… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73146/psn-pdfApril 28, 2021 - Patient Safety in Home Dialysis April 28, 2021 Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/patient-safety-home-dialysis Dialysis Care and Patient Safety Concerns In patients with chronic kidney disease, kidney function declines ov… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33824/psn-pdfJanuary 01, 2016 - Patient Safety and Opioid Medications January 1, 2016 Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications Annual Perspective 2016 Opioid medications confer significant risks of harm, including overdose death … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49563/psn-pdfMay 01, 2008 - Is It Safe to Be Direct? May 1, 2008 Kulkarni NS, Williams M. Is It Safe to Be Direct? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/it-safe-be-direct The Case A 92-year-old man with hypertension and heart failure (HF) was evaluated by his primary care physician (PCP) for progressive shortness of breat… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33679/psn-pdfJanuary 01, 2009 - Disclosure of Medical Error January 1, 2009 Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/disclosure-medical-error Perspective Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater discl… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33850/psn-pdfJanuary 01, 2018 - EHR Copy and Paste and Patient Safety January 1, 2018 Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety Perspective Although the ability to copy and paste text is a central benefit of computing in general, and electronic… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33815/psn-pdfSeptember 01, 2016 - Telemedicine and Patient Safety September 1, 2016 Agboola SO, Kvedar JC. Telemedicine and Patient Safety. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/telemedicine-and-patient-safety Perspective A paradigm shift is ongoing in the health care sector. The traditional model of episodic and hospital-base… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49701/psn-pdfFebruary 01, 2014 - An Easily Forgotten Tube February 1, 2014 Ousey K. An Easily Forgotten Tube. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/easily-forgotten-tube The Case A 45-year-old man was admitted to the intensive care unit (ICU) for acute liver failure secondary to alcohol abuse. His illness was complicated by acute… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60169/psn-pdfMarch 25, 2020 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room. March 25, 2020 Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49505/psn-pdfMarch 01, 2006 - Collegiality vs. Competence March 1, 2006 Sagin T. Collegiality vs. Competence. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/collegiality-vs-competence The Case A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective repair of a 10-cm abdominal aortic aneurys… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49435/psn-pdfFebruary 01, 2004 - X-ray Flip February 1, 2004 Shapiro MJ. X-ray Flip. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/x-ray-flip The Case A 19-year-old man presented to the emergency department with respiratory distress after blunt chest trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49845/psn-pdfOctober 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages October 1, 2018 Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages The Case A 1-month-old preterm infant in the ne… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49635/psn-pdfSeptember 01, 2011 - Central, not Epidural September 1, 2011 Simmons D. Central, not Epidural. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/central-not-epidural The Case A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively, he was awake, alert, and oriented to time, place,… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49387/psn-pdfFebruary 01, 2003 - Patient Mix-Up February 1, 2003 Shojania KG. Patient Mix-Up. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/patient-mix The Case Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general medical service at an academic medical center. Overnight, another man wit… -
psnet.ahrq.gov/primer/national-patient-safety-goalsJanuary 16, 2025 - National Patient Safety Goals Citation Text: Shaikh U. National Patient Safety Goals. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
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psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-eventsMarch 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events Citation Text: Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…
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psnet.ahrq.gov/primer/health-care-associated-infectionsDecember 15, 2024 - Healthcare-associated Infections Citation Text: Healthcare - Associated Infections. 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 t…
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