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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49600/psn-pdf
    April 01, 2010 - Bad Writing, Wrong Medication April 1, 2010 Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication Case Objectives Differentiate between a medication error and an adverse drug event. Appreciate the system complexities involved in medication erro…
  2. psnet.ahrq.gov/web-mm/harm-alarm-fatigue
    February 14, 2018 - SPOTLIGHT CASE Harm From Alarm Fatigue Citation Text: Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…
  3. psnet.ahrq.gov/web-mm/good-catch-operating-room
    August 27, 2017 - Good Catch in the Operating Room Citation Text: Day J, Paige JT. Good Catch in the Operating Room. 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 …
  4. psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
    March 07, 2012 - Liver Biopsy: Proceed With Caution Citation Text: Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49516/psn-pdf
    August 01, 2006 - Physical Diagnosis: A Lost Art? August 1, 2006 Thompson GR, Verghese A. Physical Diagnosis: A Lost Art? PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art Case Objectives Appreciate the decline in proficiency and reliance on physical examination skills among health care providers. …
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
    September 01, 2014 - PowerPoint Presentation Spotlight A Lot of Pain (Medications) 1 This presentation is based on the September 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49699/psn-pdf
    February 01, 2014 - Multifactorial Medication Mishap February 1, 2014 Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap Case Objectives Understand the system-based causes of medication errors. Describe a model for a systems approach to error analysis. Id…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33807/psn-pdf
    May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD May 1, 2016 In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd Editor's note: Dr. Drew, a nurse researcher, is the David Mortara Distinguished Professor of Physiological Nursing and…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49669/psn-pdf
    November 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49588/psn-pdf
    August 01, 2009 - Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care August 1, 2009 Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care Case…
  11. psnet.ahrq.gov/web-mm/missed-appendicitis
    March 13, 2013 - SPOTLIGHT CASE Missed Appendicitis Citation Text: Adams JG. Missed Appendicitis. 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 7 XML E…
  12. psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
    September 15, 2024 - Retained Surgical Items: Definition and Epidemiology. Citation Text: Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863308/psn-pdf
    February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy February 28, 2024 Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy The Case A…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33583/psn-pdf
    March 01, 2023 - Simulation Training March 1, 2023 Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/simulation-training Originally published in 2014 by researchers at the University of California, San Francisco. Updated in March 2023, by Jennifer J. Edwards, MS, RN, CHSE…
  15. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
    January 01, 2020 - Spotlight Spotlight Some Patients Can’t Wait: Improving Timeliness of Emergency Department Care Source and Credits • This presentation is based on the 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm • Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD ○ Editor…
  16. psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
    February 01, 2023 - SPOTLIGHT CASE When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Citation Text: Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…
  17. psnet.ahrq.gov/web-mm/transfusion-overload
    September 23, 2020 - SPOTLIGHT CASE Transfusion Overload Citation Text: Patel MS, Carson JL. Transfusion Overload. 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 XML En…
  18. psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
    January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. Citation Text: Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…
  19. psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
    May 16, 2022 - In Conversation With... Remle P. Crowe, PhD May 16, 2022  Also Read the Essay Citation Text: In Conversation With.. Remle P. Crowe, PhD . PSNet [internet]. 2022.In Conversation With... Remle P. Crowe, PhD . PSNet [internet]. Rockville (MD): Agency for Healthcare …
  20. psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
    May 16, 2022 - Identifying Safety Events in the Prehospital Setting May 16, 2022  Also Read the Conversation View more articles from the same authors. Citation Text: Crowe RP, Mossburg SE, Dowell P. Identifying Safety Events in the Prehospital Setting. PSNet [internet]. Rockvi…

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