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psnet.ahrq.gov/node/33661/psn-pdf
December 01, 2007 - record and requires that they be completed within 30 days
of discharge.(8) This is far too permissive, considering
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Answers to these questions provide a framework for considering solutions
based on patterns of behavior
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psnet.ahrq.gov/node/49560/psn-pdf
April 01, 2008 - include taking steps to ensure that the goals of care are
communicated across settings of care and considering
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psnet.ahrq.gov/node/49620/psn-pdf
February 01, 2011 - In considering how best to perform emergent airway
management in this setting, the physician should
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psnet.ahrq.gov/web-mm/or-peeping
May 01, 2015 - Although most people think of names or social security numbers when considering PHI, HIPAA regulations
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psnet.ahrq.gov/node/49596/psn-pdf
December 01, 2009 - This patient's experience illustrates several key points for those considering or advising others about
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psnet.ahrq.gov/node/49494/psn-pdf
January 01, 2006 - In
considering this question, it is important to recognize that it is essential that physicians in training
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - leadership, focusing on stronger corrective actions, measuring implementation and impact on outcomes, and considering
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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…
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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.
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Format:
Google Scholar BibTeX EndNote X3 …
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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…
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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…
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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…
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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.
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…
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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.…
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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.
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psnet.ahrq.gov/web-mm/silent-pain-neck
August 19, 2020 - In considering how best to perform emergent airway management in this setting, the physician should take
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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.
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Format:
DOI Google Scholar …
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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.
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…