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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49826/psn-pdf
    April 01, 2018 - Air on the Side of Caution April 1, 2018 Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/air-side-caution The Case A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of breath and chest pain. A decision was m…
  2. Spotlight (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
    May 01, 2018 - Spotlight Spotlight Out of Sight, Out of Mind: Out-of-Office Test Result Management 1 Source and Credits This presentation is based on the May 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Eric Poon, MD, MPH, Duke University School o…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49821/psn-pdf
    February 01, 2018 - Right Place, Right Drug, Wrong Strength February 1, 2018 Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength The Case A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area bur…
  4. Spotlight Case (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
    August 01, 2012 - Spotlight Case Spotlight Case No News May Not Be Good News 1 2 Source and Credits This presentation is based on the August 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49515/psn-pdf
    July 01, 2006 - Over Not So Easy July 1, 2006 Cucina R. Over Not So Easy. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/over-not-so-easy The Case A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On admission, she reported allergies to a number of medications as well as a …
  6. psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
    March 04, 2020 - The Hidden Harms of Hand Sanitizer Citation Text: Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49748/psn-pdf
    December 01, 2015 - Managing Ascites: Hazards of Fluid Removal December 1, 2015 Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal The Case A 50-year-old man with longstanding alcoholic cirrhosis presented to the emergency department (ED) w…
  8. psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
    December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005  View more articles from the same authors. Citation Text: Conway JB, Weingart SN. Organizational Change…
  9. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
    November 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case November 2006 Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Source and Credits This presentation is based on the November 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is…
  10. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
    October 01, 2015 - PowerPoint Presentation Spotlight The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy 1 This presentation is based on the October 2015 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/ CME credit is available Commentary by: Jacob Reider,…
  11. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
    May 01, 2012 - Spotlight Case July 2008 Spotlight Case The Perils of Cross Coverage * * Source and Credits This presentation is based on the May 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49695/psn-pdf
    October 01, 2013 - Finding Fault With the Default Alert October 1, 2013 Baysari M. Finding Fault With the Default Alert. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/finding-fault-default-alert The Case A 33-year-old man with known refractory epilepsy and developmental delay was admitted to the hospital after experiencing …
  13. psnet.ahrq.gov/web-mm/hemolysis-holdup
    July 03, 2016 - Hemolysis Holdup Citation Text: Lehman CM. Hemolysis Holdup. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  14. psnet.ahrq.gov/web-mm/mark-my-tooth
    June 01, 2014 - Mark My Tooth Citation Text: Smith RA. Mark My Tooth. 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 tagged PubMedId RIS D…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850362/psn-pdf
    June 14, 2023 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital June 14, 2023 Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33821/psn-pdf
    December 01, 2016 - Errors and Near Misses: What Health Care Could Learn From Aviation December 1, 2016 Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation Perspective Some of the most urg…
  17. Spotlight Case (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
    May 01, 2006 - Spotlight Case Spotlight Case May 2006 Right? Left? Neither! Source and Credits This presentation is based on the May 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD…
  18. psnet.ahrq.gov/web-mm/lethal-cap
    December 19, 2018 - Lethal Cap Citation Text: Schillinger D. Lethal Cap. 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 Do…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867429/psn-pdf
    December 18, 2024 - Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis December 18, 2024 Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. 2024. https://psnet.ahrq.gov/w…
  20. psnet.ahrq.gov/web-mm/getting-root-matter
    September 01, 2005 - SPOTLIGHT CASE Getting to the Root of the Matter Citation Text: Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Schola…

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