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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - SPOTLIGHT CASE
Medication Reconciliation: Whose Job Is It?
Citation Text:
Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/33771/psn-pdf
August 22, 2014 - Beyond the Hospital: the New Frontier of Patient Safety
August 22, 2014
Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
Perspective
The frontier of patient safety outside the hospital has y…
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psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
February 26, 2025 - In Conversation With…Christine A. Sinsky, MD
February 1, 2016
Citation Text:
In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - SPOTLIGHT CASE
A Painful Medication Reconciliation Mishap
Citation Text:
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Google S…
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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - SPOTLIGHT CASE
When the Lytes Go Out: A Case of Inpatient Cardiac Arrest
Citation Text:
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…
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psnet.ahrq.gov/node/49807/psn-pdf
October 01, 2017 - Translating From Normal to Abnormal
October 1, 2017
Turner AM. Translating From Normal to Abnormal. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/translating-normal-abnormal
Case Objectives
Define limited English proficiency.
Understand the principal approaches to machine translation.
Review the way mach…
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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/73300/psn-pdf
July 01, 2022 - Project BOOST Increases Patient Understanding of
Treatment and Follow-up Care
May 26, 2021
https://psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
Summary
The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge
needs,…
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
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psnet.ahrq.gov/node/836885/psn-pdf
May 16, 2022 - Management of Cardiac Arrest in Unconventional
Locations.
May 16, 2022
Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
The Case
Case #1: An 80-year-old man with history of Parkins…
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psnet.ahrq.gov/node/33720/psn-pdf
November 01, 2011 - In Conversation With… Eduardo Salas, PhD
November 1, 2011
In Conversation With… Eduardo Salas, PhD . PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
Editor's note: Eduardo Salas, PhD, is a University Trustee Chair and Pegasus Professor of Psychology at
the University of Ce…
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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound
and Patient Safety
July 1, 2018
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
Case Objectives
Unders…
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psnet.ahrq.gov/node/49684/psn-pdf
May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical
Error
May 1, 2013
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet].
2013.
https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
Case Objectives
Appreciate that chemotherapy a…
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psnet.ahrq.gov/node/49738/psn-pdf
August 21, 2015 - Privacy or Safety?
August 21, 2015
Halamka JD, McGraw D. Privacy or Safety? PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/privacy-or-safety
Case Objectives
Understand that the HIPAA Omnibus Rule is an enabler of data sharing, not a barrier.
Review common misconceptions about privacy rules.
Understand the…
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psnet.ahrq.gov/node/49615/psn-pdf
December 01, 2010 - The Forgotten Turn
December 1, 2010
Barbour S. The Forgotten Turn. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/forgotten-turn
Case Objectives
Describe the six stages of pressure ulceration per the National Pressure Ulcer Advisory Panel.
List risk factors for the development of pressure ulcers in hospita…
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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - SPOTLIGHT CASE
Unexplained Apnea Under Anesthesia
Citation Text:
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX …
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psnet.ahrq.gov/node/866343/psn-pdf
December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure
with Hypertensive Emergency
December 31, 2024
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive
Emergency. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hyperte…
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy
Citation Text:
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
February 26, 2025 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care
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May 26, 2021
Innovation
Contact
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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - The Forgotten Radiographic Read
Citation Text:
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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