-
psnet.ahrq.gov/node/49523/psn-pdf
November 01, 2006 - Urinary Retention Dilemma
November 1, 2006
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma
The Case
Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy
(BPH) and urinary hesitancy returned to th…
-
psnet.ahrq.gov/node/49578/psn-pdf
January 01, 2009 - Hospital Admission Due to High-Dose Methotrexate Drug
Interaction
January 1, 2009
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
The Case
A 40-year-old wo…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
July 01, 2011 - Spotlight Case July 2008
Spotlight Case
Watch the Warfarin!
1
2
Source and Credits
This presentation is based on the July 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Raman Khanna, MD, and Margaret Fang, MD, MPH; University of California, Sa…
-
psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - SPOTLIGHT CASE
The Case of Mistaken Intubation
Citation Text:
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX End…
-
psnet.ahrq.gov/issue/language-barriers-and-patient-safety-risks-hospital-care-mixed-methods-study
May 18, 2016 - Study
Language barriers and patient safety risks in hospital care. A mixed methods study.
Citation Text:
van Rosse F, de Bruijne M, Suurmond J, et al. Language barriers and patient safety risks in hospital care. A mixed methods study. Int J Nurs Stud. 2016;54:45-53. doi:10.1016/j.ijnurst…
-
psnet.ahrq.gov/issue/impact-implementation-family-initiated-escalation-care-deteriorating-patient-hospital
December 21, 2018 - Review
The impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review.
Citation Text:
Gill FJ, Leslie GD, Marshall AP. The Impact of Implementation of Family-Initiated Escalation of Care for the Deteriorating Patient in …
-
psnet.ahrq.gov/issue/medication-dosing-errors-patients-renal-insufficiency-ambulatory-care
July 31, 2008 - Study
Medication dosing errors for patients with renal insufficiency in ambulatory care.
Citation Text:
Yap C, Dunham D, Thompson JA, et al. Medication Dosing Errors for Patients with Renal Insufficiency in Ambulatory Care. The Joint Commission Journal on Quality and Patient Safety. 2016…
-
psnet.ahrq.gov/issue/when-doing-wrong-feels-so-right-normalization-deviance
September 03, 2011 - Review
When doing wrong feels so right: normalization of deviance.
Citation Text:
Price MR, Williams TC. When Doing Wrong Feels So Right: Normalization of Deviance. J Patient Saf. 2018;14(1):1-2. doi:10.1097/PTS.0000000000000157.
Copy Citation
Format:
DOI Google Scholar Pub…
-
psnet.ahrq.gov/issue/patient-safety-and-job-related-stress-focus-group-study
December 05, 2012 - Study
Patient safety and job-related stress: a focus group study.
Citation Text:
Berland A, Natvig GK, Gundersen D. Patient safety and job-related stress: A focus group study. Intensive and Critical Care Nursing. 2007;24(2). doi:10.1016/j.iccn.2007.11.001.
Copy Citation
Format:
…
-
psnet.ahrq.gov/issue/culture-language-and-patient-safety-making-link
June 22, 2009 - Commentary
Culture, language, and patient safety: making the link.
Citation Text:
Johnstone M-J, Kanitsaki O. Culture, language, and patient safety: Making the link. Int J Qual Health Care. 2006;18(5):383-8.
Copy Citation
Format:
Google Scholar PubMed BibTeX EndNote X3 XM…
-
psnet.ahrq.gov/node/49588/psn-pdf
August 01, 2009 - Nurse Staffing Ratios: The Crucible of Money, Policy,
Research, and Patient Care
August 1, 2009
Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
Case…
-
psnet.ahrq.gov/web-mm/dual-therapy-debacle
February 01, 2007 - Dual Therapy Debacle
Citation Text:
Kayser SR. Dual Therapy Debacle. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
-
psnet.ahrq.gov/web-mm/urinary-retention-dilemma
March 01, 2013 - Urinary Retention Dilemma
Citation Text:
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
-
psnet.ahrq.gov/issue/we-need-talk-observational-study-impact-electronic-medical-record-implementation-hospital
February 22, 2017 - Study
We need to talk: an observational study of the impact of electronic medical record implementation on hospital communication.
Citation Text:
Taylor SP, Ledford R, Palmer V, et al. We need to talk: an observational study of the impact of electronic medical record implementation on ho…
-
psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - Near Miss with Bedside Medications
November 1, 2011
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications
Case Objectives
Understanding the definition of near miss—also known as close call.
Appreciate the importance of close calls in reducin…
-
psnet.ahrq.gov/issue/less-more-project-reduce-number-pims-potentially-inappropriate-medications-elderly-care-ward
September 27, 2017 - Commentary
Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward.
Citation Text:
Aung TH, Beck AJ, Siese T, et al. Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly car…
-
psnet.ahrq.gov/issue/experiences-diagnostic-delay-among-underserved-racial-and-ethnic-patients-systematic-review
November 03, 2015 - Review
Experiences with diagnostic delay among underserved racial and ethnic patients: a systematic review of the qualitative literature.
Citation Text:
Faugno E, Galbraith AA, Walsh KE, et al. Experiences with diagnostic delay among underserved racial and ethnic patients: a systematic r…
-
psnet.ahrq.gov/issue/drug-related-morbidity-and-mortality-and-economic-impact-pharmaceutical-care
December 23, 2008 - Study
Drug-related morbidity and mortality and the economic impact of pharmaceutical care.
Citation Text:
Johnson JA, Bootman JL. Drug-related morbidity and mortality and the economic impact of pharmaceutical care. Am J Health Syst Pharm. 1997;54(5):554-8.
Copy Citation
Format:
…
-
psnet.ahrq.gov/issue/handoffs-causing-patient-harm-survey-medical-and-surgical-house-staff
July 10, 2008 - Study
Handoffs causing patient harm: a survey of medical and surgical house staff.
Citation Text:
Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34(10):563-70.
Copy Citation
Format:…
-
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 …