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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49816/psn-pdf
    January 01, 2018 - A Painful Medication Reconciliation Mishap January 1, 2018 Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap Case Objectives Recognize that substance use disorders are common in patients with acute pain. Understand th…
  2. psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx Spotlight Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49760/psn-pdf
    May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…
  4. psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
    April 09, 2014 - SPOTLIGHT CASE The Hazards of Distraction: Ticking All the EHR Boxes Citation Text: Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49864/psn-pdf
    June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49558/psn-pdf
    April 01, 2008 - Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad April 1, 2008 Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad Case Objectives Understand the indications for antibiotic treatment in …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33877/psn-pdf
    April 01, 2019 - In Conversation With… Timothy B. McDonald, MD, JD April 1, 2019 In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd Editor's note: Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar…
  8. psnet.ahrq.gov/web-mm/check-twice-transport-once
    March 15, 2023 - Check Twice, Transport Once Citation Text: DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …
  9. psnet.ahrq.gov/web-mm/discharging-our-responsibility
    January 16, 2019 - Discharging Our Responsibility Citation Text: Fonarow GC. Discharging Our Responsibility. 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 End…
  10. psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
    January 29, 2021 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. Citation Text: Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863650/psn-pdf
    February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance Measurement Tracking, and Performance Feedback February 28, 2024 https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking- and-performance Summary To improve patient care and outcomes in the intensive care unit (ICU…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49570/psn-pdf
    October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure? October 1, 2008 Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure Case Objectives Understand the complementary abilities of an electronic health record a…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33839/psn-pdf
    August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS August 1, 2017 In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwester…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33767/psn-pdf
    May 01, 2014 - Innovations in Promoting Hand Hygiene Compliance May 1, 2014 Marra AR, Edmond MB. Innovations in Promoting Hand Hygiene Compliance. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance Perspective One hundred sixty-five years after the publication of Ignaz Semmel…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49654/psn-pdf
    June 01, 2012 - Transfer Troubles June 1, 2012 Hains IM. Transfer Troubles. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfer-troubles Case Objectives Recognize that transfer of patients between hospitals is common. Understand the frequency of errors and adverse events in the transfer of patients between hospitals. …
  16. psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
    February 26, 2025 - In Conversation With… Ann L. Hendrich, RN, PhD December 1, 2011  Citation Text: In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Cita…
  17. psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx Spotlight Code Status vs. Care Status Source and Credits • This presentation is based on the December 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Rebe…
  18. Spotlight (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
    January 01, 2019 - Spotlight Spotlight Mistaken Attribution, Diagnostic Misstep * Source and Credits This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49498/psn-pdf
    January 01, 2006 - An Ounce of Prevention January 1, 2006 Kucher N. An Ounce of Prevention. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/ounce-prevention Case Objectives Assess risk for venous thromboembolism (VTE) in hospitalized patients List recommended strategies for VTE prevention for various risk groups Identify pat…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33822/psn-pdf
    January 01, 2017 - In Conversation With… Paul H. O'Neill, MPA January 1, 2017 In Conversation With… Paul H. O'Neill, MPA. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa Editor's note: Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prio…

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