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psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
Discharged with IV antibiotics:
When issues arise, who manages
the complications?
Source and Credits
• This presentation is based on the February 2020 AHRQ
WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Monica Donnel…
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/node/33719/psn-pdf
October 01, 2011 - The Context Is the Intervention
October 1, 2011
Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/context-intervention
Perspective
Introduction
What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this
context.…
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psnet.ahrq.gov/node/33694/psn-pdf
April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA
April 1, 2010
In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a
priva…
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psnet.ahrq.gov/node/33629/psn-pdf
March 01, 2006 - What Does Simulation Add to Teamwork Training?
March 1, 2006
Gaba DM. What Does Simulation Add to Teamwork Training? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training
Editor's Note: In these point–counterpoint articles, Drs. Pratt and Sachs of Beth Israel Deacones…
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psnet.ahrq.gov/node/49599/psn-pdf
February 23, 2010 - Defensive Medicine: "Glowing" with Pain
February 1, 2010
Sethi MK. Defensive Medicine: "Glowing" with Pain. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
The Case
A 31-year-old man presented to the emergency department (ED) complaining of abdominal pain and
vomiting. The…
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psnet.ahrq.gov/node/49596/psn-pdf
December 01, 2009 - Round-Trip Service
December 1, 2009
McGrath MH. Round-Trip Service. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/round-trip-service
The Case
A 70-year-old man with a long history of degenerative joint disease was experiencing increased symptoms
in his left knee. He was referred by his primary care provid…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/49782/psn-pdf
January 01, 2017 - A Potent Medication Administered in a Not So Viable
Route
January 1, 2017
Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
The Case
A 55-year-old man with history of nonischemic cardiomyop…
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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/node/49453/psn-pdf
July 01, 2004 - Bowel Prep
July 1, 2004
Nelson D. Bowel Prep. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/bowel-prep
The Case
The patient is a 73-year-old woman who 20 years ago underwent treatment for breast cancer. At her
daughter's suggestion, the patient requested referral for colonoscopy, as she understood there w…
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psnet.ahrq.gov/node/33856/psn-pdf
April 01, 2018 - Patient Safety During Hospital Discharge
April 1, 2018
Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
Perspective
Patients are admitted to the hospital in the United States 35 million times per year.(1)…
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psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - Hold the tPA
Citation Text:
Fagan SC. Hold the tPA. 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 tagged PubMedId RIS
Dow…
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - Delayed Diagnosis of Mesenteric Ischemia
August 31, 2022
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for…
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psnet.ahrq.gov/node/73553/psn-pdf
July 28, 2021 - In Conversation With... James Augustine, MD
July 28, 2021
In Conversation With.. James Augustine, MD. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-james-augustine-md
Editor’s Note: James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care
Solutions where he p…
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psnet.ahrq.gov/node/33873/psn-pdf
February 01, 2019 - In Conversation With… Susan E. Skochelak, MD, PhD
February 1, 2019
In Conversation With… Susan E. Skochelak, MD, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
Editor's note: Dr. Skochelak is the Group Vice President for Medical Education at the American Medica…
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psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
April 26, 2023 - Annual Perspective
Technology as a Tool for Improving Patient Safety
A Jay Holmgren, Susan McBride,Bryan Gale, Sarah Mossburg
| March 29, 2023
View more articles from the same authors.
Citation Text:
Holmgren AJ, McBride S, Gale B, et al. Technology as a …
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
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May 29, 2024
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Inno…
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psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
April 04, 2018 - SPOTLIGHT CASE
The Pains of Chronic Opioid Usage
Citation Text:
Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google S…
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - SPOTLIGHT CASE
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
Citation Text:
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…