-
psnet.ahrq.gov/node/72586/psn-pdf
December 23, 2020 - Furthermore, healthcare systems are encouraged to always be
ready situations in which demand for hospital
-
psnet.ahrq.gov/perspective/conversation-susan-smith-md
August 01, 2019 - Order repeat-back is encouraged, particularly for new medication orders.
-
psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - They encouraged us to keep moving forward.
-
psnet.ahrq.gov/web-mm/code-status-vs-care-status
September 30, 2020 - Furthermore, healthcare systems are encouraged to always be ready situations in which demand for hospital
-
psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - They encouraged us to keep moving forward.
-
psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - Hyperglycemia and Switching to Subcutaneous Insulin
Citation Text:
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Sc…
-
psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Medication Mix-Up: From Bad to Worse
Citation Text:
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. 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 …
-
psnet.ahrq.gov/web-mm/more-treatment-better-care
August 11, 2021 - More Treatment—Better Care?
Citation Text:
Redberg R. More Treatment—Better Care?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
-
psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - SPOTLIGHT CASE
Double Trouble
Citation Text:
Gurwitz JH. Double Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
-
psnet.ahrq.gov/node/850675/psn-pdf
June 14, 2023 - Patient and Family Roles in Safety
June 14, 2023
Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety
Moving From Engagement to Partnership
Involving patients and families in healthcare decisions about patient c…
-
psnet.ahrq.gov/node/60269/psn-pdf
April 29, 2020 - Delayed Management of Necrotizing Soft Tissue Infection
– Who does the Patient Belong To?
April 29, 2020
Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the
Patient Belong To? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tiss…
-
psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - Root Cause Analysis Gone Wrong
May 1, 2018
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
The Case
A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney
transplant. A suitabl…
-
psnet.ahrq.gov/node/49570/psn-pdf
October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure?
October 1, 2008
Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
Case Objectives
Understand the complementary abilities of an electronic health record a…
-
psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
January 01, 2021 - Spotlight
Spotlight
Two Cases of Retained Vaginal Packing:
When Writing an Order is Not Enough
Source and Credits
• This presentation is based on the April 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Verna Gibbs, MD
o AHRQ W…
-
psnet.ahrq.gov/node/49865/psn-pdf
June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy
June 1, 2019
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
The Case
A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
-
psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
February 26, 2025 - In Conversation With… Ann L. Hendrich, RN, PhD
December 1, 2011
Citation Text:
In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Cita…
-
psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - Delayed Diagnosis and Treatment of an Occult
Hemothorax Following Complicated Central Line Insertion
Leads to Cardiac Arrest
January 26, 2022
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated
Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022.
https…
-
psnet.ahrq.gov/node/49712/psn-pdf
June 01, 2014 - May I Have Another?—Medication Error
June 1, 2014
Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
The Case
A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a
pharmacology-tra…
-
psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - Death by PCA
February 1, 2013
Hicks RW. Death by PCA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/death-pca
The Case
A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an
uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
-
psnet.ahrq.gov/node/854848/psn-pdf
October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures
October 31, 2023
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
The Case
A 32-year-old man presented to the hospital with…