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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50696/psn-pdf
    November 27, 2019 - Complications of Vascular Access Procedures in Patients with Kidney Disease November 27, 2019 Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease The Ca…
  2. Psn-Pdf (pdf file)

    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…
  3. psnet.ahrq.gov/web-mm/abnormal-volunteer-results
    July 18, 2016 - Abnormal Volunteer Results Citation Text: Fernandez C. Abnormal Volunteer Results. 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 ta…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49457/psn-pdf
    September 01, 2004 - Doctor, Don't Treat Thyself September 1, 2004 Rosvold EO. Doctor, Don't Treat Thyself. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself The Case A 50-year-old radiologist presented to the emergency department of the community hospital where he worked and reported increasing shortnes…
  5. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.350_slideshow.ppt
    June 01, 2015 - PowerPoint Presentation Spotlight Anchoring Bias With Critical Implications 1 This presentation is based on the June 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Edward Etchells, MD, MSc, Division of General Internal Medicine, Centre for Q…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49426/psn-pdf
    November 01, 2003 - Don't Push November 1, 2003 Meltzer HY. Don't Push. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dont-push The Case A 37-year-old HIV-positive woman was brought to the emergency room by her family because she had exhibited altered mentation for 3 days. The patient had been diagnosed with HIV infection 3 …
  7. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
    April 01, 2013 - Spotlight Case July 2008 Spotlight Case Total Parenteral Nutrition, Multifarious Errors * * Source and Credits This presentation is based on the April 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Joseph I. Boullata, PharmD, RPh, BCNSP…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49489/psn-pdf
    September 01, 2005 - Double Trouble September 1, 2005 Gurwitz JH. Double Trouble. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/double-trouble Case Objectives Appreciate the incidence of adverse drug events in older persons List preventative measures that can be used to minimize medication errors in this population Encourage…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836978/psn-pdf
    May 16, 2022 - Check Twice, Transport Once May 16, 2022 DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/check-twice-transport-once The Case Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal pain and was diagnosed with “s…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49490/psn-pdf
    September 01, 2005 - The Wrong Channel September 1, 2005 Gosbee JW. The Wrong Channel . PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/wrong-channel The Case A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial dosing started at 50 mL/hour using a multi-channel medication pump…
  11. psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
    June 29, 2020 - Annual Perspective Pharmacist Role in Patient Safety February 21, 2020  View more articles from the same authors. Citation Text: Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
  12. psnet.ahrq.gov/web-mm/electronic-err
    April 01, 2014 - Electronic Err Citation Text: Tang PC. Electronic Err. 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 7 XML Endnote tagged PubMedId RIS …
  13. psnet.ahrq.gov/innovation/catching-those-who-fall-through-cracks-integrating-follow-process-emergency-department
    September 09, 2020 - EMERGING INNOVATIONS Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings. Citation Text: Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33803/psn-pdf
    January 01, 2015 - RK: AHRQ publishes an annual report that describes many measures of quality, safety, and disparities.
  15. psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
    September 27, 2023 - Review Process As of 2018, The Joint Commission requires hospitals using ADCs to have a policy that describes
  16. psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx Spotlight The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Source and Credits • This presentation is based on the November 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahr…
  17. psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
    September 27, 2023 - SPOTLIGHT CASE Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations Citation Text: Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. Agency for Healthcare Research and Qu…
  18. psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
    November 25, 2020 - EMS Perils from Hospital Overcrowding Citation Text: Brown S, Rose JS, Barnes DK. EMS Perils from Hospital Overcrowding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX E…
  19. psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
    August 01, 2012 - SPOTLIGHT CASE The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Citation Text: Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
  20. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
    May 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer? * * Source and Credits This presentation is based on the May 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Sidney W.A. Dekker, Ph…

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