-
psnet.ahrq.gov/node/49711/psn-pdf
June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of
Patient Wandering
June 1, 2014
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
Case Objectives
Define patie…
-
psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - Double Dosing, by the Rules
Citation Text:
Cohen H. Double Dosing, by the Rules. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
-
psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Spotlight
Spotlight
Dangers of Missing an Epidural Abscess:
Multiple Visits and Delayed Diagnosis with
a Severely Negative Outcome
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Comm…
-
psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - testing is sometimes considered adjunctive to RT-PCR testing,35 and current CDC guidelines recommend
considering
-
psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx
Spotlight
A Missed Bowel Perforation – the Importance of
Diagnostic Reasoning
Source and Credits
• This presentation is based on the September 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/web…
-
psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - settings/primary-care/toolkit .( 11,12 ) Importantly, suicidal ideation (defined as thinking about or considering
-
psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - Spotlight
Spotlight
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
1
Source and Credits
This presentation is based on the September 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: David…
-
psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - SPOTLIGHT CASE
Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome
Citation Text:
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet…
-
psnet.ahrq.gov/web-mm/mitigating-risk-intrahospital-transport-pediatric-patients-risk-physiologic-instability
May 27, 2020 - benefits of the diagnostic or therapeutic intervention requiring intrahospital transport while also considering
-
psnet.ahrq.gov/node/846770/psn-pdf
March 29, 2023 - Developing a hospital workflow while considering these factors will help ensure timely and
safe transition
-
psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - Managing Ascites: Hazards of Fluid Removal
Citation Text:
Moore K. Managing Ascites: Hazards of Fluid Removal. 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 …
-
psnet.ahrq.gov/node/49706/psn-pdf
January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication
Access Issue
April 1, 2014
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
The Case
A 24-year-old wom…
-
psnet.ahrq.gov/node/49529/psn-pdf
February 01, 2007 - Crossed Coverage
February 1, 2007
Kayser SR. Crossed Coverage. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/crossed-coverage
The Case
A 27-year-old woman with a history of congenital heart disease was admitted for cardiac transplantation
evaluation. She had already undergone multiple surgeries, including…
-
psnet.ahrq.gov/issue/iv-push-gap-analysis-tool-gat-helps-uncover-national-priorities-safe-injection-practices
August 14, 2019 - Newspaper/Magazine Article
IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices.
Citation Text:
IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. ISMP Medication Safety Alert! Acute Care Edition. Augu…
-
psnet.ahrq.gov/issue/independent-double-checks-worth-effort-if-used-judiciously-and-properly
January 23, 2019 - Newspaper/Magazine Article
Independent double checks: worth the effort if used judiciously and properly.
Citation Text:
Independent double checks: worth the effort if used judiciously and properly. ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24:1-7.
Copy Citation
…
-
psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
-
psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - SPOTLIGHT CASE
Patient Safety Events Involving Opioid Dose Stacking
Citation Text:
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
Copy Cita…
-
psnet.ahrq.gov/issue/development-and-implementation-checklists-obstetrics
July 13, 2010 - Commentary
The development and implementation of checklists in obstetrics.
Citation Text:
Medicine S for M-F, Bernstein PS, Combs A, et al. The development and implementation of checklists in obstetrics. Am J Obstet Gynecol. 2017;217(2):B2-B6. doi:10.1016/j.ajog.2017.05.032.
Copy Citat…
-
psnet.ahrq.gov/issue/inpatient-suicide-preventing-common-sentinel-event
May 28, 2015 - Review
Inpatient suicide: preventing a common sentinel event.
Citation Text:
Tishler CL, Reiss NS. Inpatient suicide: preventing a common sentinel event. Gen Hosp Psychiatry. 2009;31(2):103-9. doi:10.1016/j.genhosppsych.2008.09.007.
Copy Citation
Format:
DOI Google Scholar …
-
psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - Crossed Coverage
Citation Text:
Kayser SR. Crossed Coverage. 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 Endnote tagged PubMedId RIS
…