-
psnet.ahrq.gov/node/838900/psn-pdf
October 27, 2022 - Fecal Contamination of the Peritoneum from
Laparoscopic Trocar Injury: A Routine Operation Goes
Wrong.
October 27, 2022
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine
Operation Goes Wrong. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/fecal-contamination-…
-
psnet.ahrq.gov/node/49723/psn-pdf
January 01, 2015 - Monitoring Fetal Health
January 1, 2015
Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/monitoring-fetal-health
Case Objectives
Define fetal heart rate monitoring.
Describe the current state of evidence regarding fetal heart rate monitoring.
List the known …
-
psnet.ahrq.gov/node/49792/psn-pdf
May 01, 2017 - Diagnostic Delay in the Emergency Department
May 1, 2017
Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
Case Objectives
Appreciate the importance of a broad differential diagnosis for acute abdominal pai…
-
psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx
Spotlight
Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/…
-
psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - SPOTLIGHT CASE
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
Citation Text:
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…
-
psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - SPOTLIGHT CASE
Isolated Clot, Real Error
Citation Text:
Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
-
psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis.
Citation Text:
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citation
Format:
Google Scholar Bi…
-
psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - Misplaced Nasogastric Tube Resulting in Aspiration
Citation Text:
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
Copy Citation
Format:
Google S…
-
psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
August 31, 2022 - SPOTLIGHT CASE
Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.
Citation Text:
Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
-
psnet.ahrq.gov/node/866618/psn-pdf
December 31, 2024 - A Fatal Twist in Pseudohyperkalemia
December 31, 2024
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council
for C…
-
psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy
March 10, 2021
Also Read the Essay
Citation Text:
In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021.In Conversation With... Libby Hoy and Stephen Hoy. PSNet [internet]. Rockville (MD): Agenc…
-
psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx
Spotlight
The Dose Makes the Poison: Medication Error During
Procedural Sedation in the Pediatric Emergency
Department
Source and Credits
• This presentation is based on the April 2023 AH…
-
psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Review Process
As of 2018, The Joint Commission requires hospitals using ADCs to have a policy that describes
-
psnet.ahrq.gov/issue/clinician-perspectives-electronic-health-records-communication-and-patient-safety-across
September 23, 2020 - Study
Clinician perspectives on electronic health records, communication, and patient safety across diverse medical oncology practices.
Citation Text:
Patel MR, Friese CR, Mendelsohn-Victor K, et al. Clinician Perspectives on Electronic Health Records, Communication, and Patient Safety A…
-
psnet.ahrq.gov/issue/state-legal-restrictions-and-prescription-opioid-use-among-disabled-adults
May 31, 2023 - Study
Classic
State legal restrictions and prescription-opioid use among disabled adults.
Citation Text:
Meara E, Horwitz JR, Powell W, et al. State Legal Restrictions and Prescription-Opioid Use among Disabled Adults. N Engl J Med. 2016;375(1):44-53. doi:10.105…
-
psnet.ahrq.gov/issue/how-effective-are-patient-safety-initiatives-retrospective-patient-record-review-study
March 18, 2013 - Study
Classic
How effective are patient safety initiatives? A retrospective patient record review study of changes to patient safety over time.
Citation Text:
Baines RJ, Langelaan M, de Bruijne M, et al. How effective are patient safety initiatives? A retrospect…
-
psnet.ahrq.gov/issue/improving-patient-safety-and-efficiency-medication-reconciliation-through-development-and
May 20, 2020 - Study
Improving patient safety and efficiency of medication reconciliation through the development and adoption of a computer-assisted tool with automated electronic integration of population-based community drug data: the RightRx project.
Citation Text:
Tamblyn R, Winslade N, Lee TC, et…
-
psnet.ahrq.gov/issue/what-needed-sustain-improvements-hospital-practices-post-covid-19-qualitative-study
August 10, 2022 - Study
What is needed to sustain improvements in hospital practices post-COVID-19? A qualitative study of interprofessional dissonance in hospital infection prevention and control.
Citation Text:
Gilbert GL, Kerridge I. What is needed to sustain improvements in hospital practices post-COV…
-
psnet.ahrq.gov/issue/effect-health-information-exchange-recognition-medication-discrepancies-interrupted-when-data
November 16, 2022 - Study
Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial.
Citation Text:
Boockvar K, Ho W, Pruskowski J, et al. Effect of health information exchange on recogni…
-
psnet.ahrq.gov/issue/primary-care-physicians-willingness-disclose-oncology-errors-involving-multiple-providers
July 28, 2014 - Study
Primary care physicians' willingness to disclose oncology errors involving multiple providers to patients.
Citation Text:
Mazor KM, Roblin DW, Greene SM, et al. Primary care physicians' willingness to disclose oncology errors involving multiple providers to patients. BMJ Qual Saf. …