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psnet.ahrq.gov/node/49870/psn-pdf
August 10, 2019 - Anemia and Delayed Colon Cancer Diagnosis
August 10, 2019
Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
Case Objectives
Describe the initial evaluation for iron deficiency anemia in elderly adults…
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - SPOTLIGHT CASE
Crossing the Line
Citation Text:
Feldman JP, Gould MK. Crossing the Line. 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…
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psnet.ahrq.gov/node/49729/psn-pdf
April 01, 2015 - Dissecting the Presentation
April 1, 2015
Suat-Ooi SB. Dissecting the Presentation. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/dissecting-presentation
Case Objectives
Define aortic dissection.
Describe the epidemiology of acute aortic dissection.
State the common and uncommon presentation of acute aor…
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - SPOTLIGHT CASE
Pseudo-obstruction But a Real Perforation
Citation Text:
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
…
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - Implementing a Fall Prevention Program
Frances Healey, RN, PhD | December 1, 2011
View more articles from the same authors.
Citation Text:
Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
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psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - SPOTLIGHT CASE
Elopement
Citation Text:
Gerardi D. Elopement. 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 PubMe…
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psnet.ahrq.gov/node/49771/psn-pdf
July 01, 2016 - Unintended Consequences of CPOE
October 1, 2016
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
Case Objectives
Explain how technology, including computerized provider order entry, can transform, rather than
eliminate, hazards.
Recogni…
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psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing
October 30, 2019
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
Case Objectives
List the most common errors associated with computerized…
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - SPOTLIGHT CASE
Diagnosing Diagnostic Mistakes
Citation Text:
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google S…
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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - SPOTLIGHT CASE
Order Interrupted by Text: Multitasking Mishap
Citation Text:
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
…
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psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
June 01, 2015 - SPOTLIGHT CASE
Empiric Steroids: the Good, the Bad, and the Ugly
Citation Text:
Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:…
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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…
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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…
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psnet.ahrq.gov/node/33770/psn-pdf
August 01, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH
August 1, 2014
In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
Editor's note: Urmimala Sarkar, MD, MPH, is associate professor of medicine at the University of
California, S…
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psnet.ahrq.gov/node/60865/psn-pdf
August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-
BC-FACHE
August 31, 2020
In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
Editor’s Note: Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is …
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the
Senior Clinical Data Analyst at Atrium Health, and Rhonda
Dickman, MSN, RN, CPHQ, the Director of the Tennessee
Hospital Association PSO
January 12, 2022
In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and
Rhonda…
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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions
April 28, 2021
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
The Case
A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and
severe e…
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psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse
Outcomes
July 8, 2022
Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
The Cases
Case 1: A 64-year-old man came in for a routine bron…
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psnet.ahrq.gov/node/33732/psn-pdf
July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP
July 1, 2012
In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
Editor's note: David Blumenthal, MD, MPP, is Chief Health Information and Innovation Officer, Partners
Healt…
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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…