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5861. Picking Up the Cause of the Stroke | PSNet
      psnet.ahrq.gov/web-mm/picking-cause-stroke
      August 07, 2024 - Picking Up the Cause of the Stroke Citation Text: Chopra V. Picking Up the Cause of the Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

5862. Tacit Handover, Overt Mishap | PSNet
      psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
      August 01, 2006 - Tacit Handover, Overt Mishap Citation Text: Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

5863. Too Tight Control | PSNet
      psnet.ahrq.gov/web-mm/too-tight-control
      March 20, 2013 - SPOTLIGHT CASE Too Tight Control Citation Text: Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…

5864. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837659/psn-pdf
      July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging July 8, 2022 Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging The Cases Case #1: A 42-year-old woman admitted with…

5865. 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…

5866. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49639/psn-pdf
      November 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin…

5867. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33738/psn-pdf
      December 01, 2012 - In Conversation With... John G. Reiling, PhD December 1, 2012 In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd Editor's note: John G. Reiling, PhD, is president and CEO of Safe by Design. Dr. Reiling consults with hospitals and…

5868. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49705/psn-pdf
      January 01, 2020 - A "Reflexive" Diagnosis in Primary Care April 1, 2014 Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care Case Objectives Appreciate that primary care doctors may be caring for an increasing number of patients wi…

5869. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49663/psn-pdf
      September 01, 2012 - Peripheral IV in Too Long September 1, 2012 Fang C-T. Peripheral IV in Too Long. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/peripheral-iv-too-long Case Objectives Appreciate the complications associated with peripheral intravenous (IV) catheters. Describe the optimal sterile technique that should be us…

5870. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.113_slideshow.ppt
      January 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case January 2006 An Ounce of Prevention Source and Credits This presentation is based on the Jan. 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Nils Kucher, MD; University Ho…

5871. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49408/psn-pdf
      July 01, 2003 - Check the Wristband July 1, 2003 Rosenthal M. Check the Wristband. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/check-wristband The Case The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the impending surgery. The patient spoke English and appeared to be of aver…

5872. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49552/psn-pdf
      January 01, 2008 - How Do Providers Recover From Errors? January 1, 2008 West CP. How Do Providers Recover From Errors? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors Case Objectives Describe the provider-specific prevalence of medical errors. Appreciate the impact of medical errors on care pr…

5873. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836841/psn-pdf
      June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission April 7, 2022 https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and- paramedics-provide-home Sum…

5874. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33635/psn-pdf
      July 01, 2006 - In Conversation with...Allan Frankel, MD July 1, 2006 In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this kind of work. Dr. Allan …

5875. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49799/psn-pdf
      July 01, 2017 - Delayed Recognition of a Positive Blood Culture July 1, 2017 Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture The Case A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…

5876. 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…

5877. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49485/psn-pdf
      August 29, 2024 - Blind Spot June 1, 2005 Lee LA. Blind Spot. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/blind-spot The Case A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…

5878. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842923/psn-pdf
      February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. February 1, 2023 Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …

5879. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49584/psn-pdf
      April 01, 2009 - EMR Entry Error: Not So Benign April 1, 2009 Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign The Case A 47-year-old man with advanced AIDS was admitted to an academic medical center with a chief complaint of shortness of breath. He was …

5880. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49678/psn-pdf
      March 01, 2013 - A Weighty Mistake March 1, 2013 Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/weighty-mistake Case Objectives Understand factors associated with weight-based dosing medication errors in pediatric populations. Describe how adoption of computerized provider order entry (CPOE) s…