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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
December 01, 2011 - Spotlight Case July 2008
Spotlight Case
Order Interrupted by Text: Multitasking Mishap
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Source and Credits
This presentation is based on the December 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John Halamka, MD, MS, Chief Informa…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
May 01, 2013 - Spotlight Case July 2008
Spotlight Case
Right Regimen, Wrong Cancer: Patient Catches Medical Error
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Source and Credits
This presentation is based on the May 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Joseph O. Jacobson, MD, MSc…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
September 01, 2003 - Spotlight Case September 2003
Spotlight Case September 2003
Infant Paralyzed for Intubation Before Airway Materials Ready
Source and Credits
This presentation is based on the Sept. 2003 AHRQ WebM&M Spotlight Case in Pediatrics
See the full article at http://webmm.ahrq.gov
CME credit is available through the …
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psnet.ahrq.gov/node/33755/psn-pdf
September 01, 2013 - What We've Learned About Leveraging Leadership and
Culture to Affect Change and Improve Patient Safety
September 1, 2013
Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve
Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/what-weve-learned-ab…
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - SPOTLIGHT CASE
A Missed Bowel Perforation - the Importance of Diagnostic Reasoning
Citation Text:
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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psnet.ahrq.gov/node/837959/psn-pdf
August 31, 2022 - Perioperative Anaphylaxis After Insertion of a Latex Drain
in a Patient with Known Latex Allergy
August 31, 2022
Kelly KJ. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertio…
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - SPOTLIGHT CASE
Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture
Citation Text:
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - SPOTLIGHT CASE
Mobility Lost in the ICU
Citation Text:
Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNot…
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psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Intraosseous Line Extravasation in a
Pediatric Trauma Patient
Source and Credits
• This presentation is based on the April 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: David Barnes, MD and Joseph Yoon, MD
o…
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psnet.ahrq.gov/node/49561/psn-pdf
May 01, 2008 - Diagnosing HIV-It Doesn't Take a Brain Surgeon
May 1, 2008
Chou R. Diagnosing HIV-It Doesn't Take a Brain Surgeon. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
Case Objectives
Describe the current epidemiology of HIV infection.
Identify the risk factors for HIV…
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psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD
August 1, 2016
Also Read an Essay
Citation Text:
In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Heal…
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx
Spotlight
Overdose of Gabapentin and Oxycodone in a Patient
with End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotl…
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psnet.ahrq.gov/issue/designing-decision-support-insulin-ordering-computerized-provider-order-entry-system
March 09, 2011 - Study
Designing decision support for insulin ordering in a computerized provider order entry system.
Citation Text:
Wright L, Feldott CC, Hargrove FR. Designing Decision Support for Insulin Ordering in a Computerized Provider Order Entry System. Hosp Pharm. 2010;42(2). doi:10.1310/hpj4…
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psnet.ahrq.gov/issue/medication-prescribing-errors-involving-route-administration
January 12, 2011 - Study
Medication prescribing errors involving the route of administration.
Citation Text:
Lesar TS. Medication Prescribing Errors Involving the Route of Administration. Hosp Pharm. 2010;41(11):1053-1066. doi:10.1310/hpj4111-1053.
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Format:
DOI Google Scholar Bib…
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psnet.ahrq.gov/issue/airway-carts-systems-based-approach-airway-safety
July 21, 2010 - Study
Airway carts: a systems-based approach to airway safety.
Citation Text:
Kane BG, Bond WF, Worrilow CC, et al. Airway Carts. J Patient Saf. 2008;2(3). doi:10.1097/01.jps.0000242995.09037.07.
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Format:
DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
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psnet.ahrq.gov/issue/medication-therapy-management-programs-forming-new-cornerstone-quality-and-safety-medicare
January 06, 2017 - Commentary
Medication therapy management programs: forming a new cornerstone for quality and safety in Medicare.
Citation Text:
Smith SR, Clancy CM. Medication therapy management programs: forming a new cornerstone for quality and safety in medicare. Am J Med Qual. 2006;21(4):276-9.
…
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psnet.ahrq.gov/issue/high-risk-high-alert-medication-management-practices-regional-state-psychiatric-facility
January 06, 2017 - Study
High-risk, high-alert medication management practices in a regional state psychiatric facility.
Citation Text:
McKee J, Cleary S. High-Risk, High-Alert Medication Management Practices in a Regional State Psychiatric Facility. Hosp Pharm. 2007;42(4):323-330. doi:10.1310/hpj4204-323.…
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psnet.ahrq.gov/issue/effective-discharge-communication-emergency-department
January 24, 2024 - Review
Effective discharge communication in the emergency department.
Citation Text:
Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med. 2012;60(2):152-9. doi:10.1016/j.annemergmed.2011.10.023.
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Format:…
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psnet.ahrq.gov/issue/restoring-trust-va-health-care
June 21, 2016 - Commentary
Restoring trust in VA health care.
Citation Text:
Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014;371(4):295-297. doi:10.1056/NEJMp1406852.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
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psnet.ahrq.gov/issue/internal-bleeding-truth-behind-americas-terrifying-epidemic-medical-mistakes-updated-edition
March 27, 2005 - Book/Report
Classic
Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Updated edition.
Citation Text:
Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Updated edition. Wachter R, Shojan…