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7081. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
      January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…

7082. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74713/psn-pdf
      January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking January 26, 2022 Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking Disclosure of Relevant Financial Relationships: As a provider ac…

7083. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49666/psn-pdf
      October 01, 2012 - CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure October 1, 2012 Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure Case Objectives Identify risk f…

7084. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49486/psn-pdf
      August 21, 2005 - Impatient Inpatient Dosing August 21, 2005 White RH. Impatient Inpatient Dosing. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/impatient-inpatient-dosing Case Objectives Appreciate the challenges of initiating warfarin therapy in the hospitalized patient Understand the fundamental pharmacology of warfarin…

7085. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49858/psn-pdf
      April 01, 2019 - What Happened on Telemetry? April 1, 2019 Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/what-happened-telemetry Case Objectives Describe current hospital practices for continuous telemetry monitoring. Appreciate key recommendations from the Update to Practice…

7086. 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…

7087. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73300/psn-pdf
      July 01, 2022 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care May 26, 2021 https://psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care Summary The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs,…

7088. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865540/psn-pdf
      April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration April 11, 2024 Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration The Case An 82-year-old woman presented to the Emergency Department (ED) for …

7089. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49735/psn-pdf
      June 01, 2015 - Anchoring Bias With Critical Implications June 1, 2015 Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications Case Objectives Appreciate that diagnostic errors are common in primary and ambulatory care. Define premature clo…

7090. Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
      January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx Spotlight Respiratory Distress after Neck Surgery: Two Cases of Post-Operative Cervical Hematoma Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…

7091. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49840/psn-pdf
      September 01, 2018 - Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care September 1, 2018 Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adver…

7092. Nursing and Patient Safety | PSNet
      psnet.ahrq.gov/primer/nursing-and-patient-safety
      September 15, 2024 - Nursing and Patient Safety Citation Text: Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…

7093. Technical Expert Panel | PSNet
      psnet.ahrq.gov/Information/Panel
      January 01, 2012 - Browse Author Resources Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …

7094. Organizational Learning | PSNet
      psnet.ahrq.gov/curated-library/organizational-learning
      September 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Organizational Learning  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…

7095. Medication Safety Events Related to Diagnostic Imaging | PSNet
      psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
      January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging Citation Text: Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…

7096. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49579/psn-pdf
      March 21, 2009 - All in the History March 21, 2009 Fee C. All in the History. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/all-history Case Objectives Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it does not apply to transfers to emergency departments from non-acute care faci…

7097. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49519/psn-pdf
      September 01, 2006 - Triple Handoff September 1, 2006 Vidyarthi A. Triple Handoff. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/triple-handoff Case Objectives Appreciate the prevalence of handoffs and sign out related errors. Understand the key elements of a safe and effective written and verbal sign out. List Kotter’s 8 st…

7098. The Missing Abscess: Radiology Reads in the Digital Era | PSNet
      psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
      January 01, 2009 - SPOTLIGHT CASE The Missing Abscess: Radiology Reads in the Digital Era Citation Text: Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation…

7099. Missed CANDOR Implementation Opportunities. | PSNet
      psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
      November 11, 2020 - Missed CANDOR Implementation Opportunities. Citation Text: Schweitzer L. Missed CANDOR Implementation Opportunities.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndN…

7100. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33607/psn-pdf
      September 27, 2022 - Burnout September 27, 2022 Yellowlees P, Rea M. Burnout. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/burnout Originally published in December 2011 by researchers at the University of California, San Francisco. Updated in September 2022 by Peter Yellowlees, MD and Margaret Rea, PhD. PSNet primers are regu…