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psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - Medication Mix-Up Leads to Patient Death
November 30, 2023
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
The Case
An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
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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…
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psnet.ahrq.gov/node/33769/psn-pdf
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things
Changed?
June 1, 2014
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
Perspective
In 1981, a cancer patient named Paula Carroll founded…
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous
Combination
April 24, 2024
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous
Combination. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
The Case
A 26-ye…
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psnet.ahrq.gov/node/49779/psn-pdf
January 01, 2017 - The Empty Bag
December 1, 2016
Vincent C. The Empty Bag. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/empty-bag
The Case
A 90-year-old woman with end-stage dementia was admitted to an acute care hospital for treatment of a
hip fracture after a fall at a nursing home. During the hospitalization, her kidne…
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psnet.ahrq.gov/node/49705/psn-pdf
January 01, 2020 - A "Reflexive" Diagnosis in Primary Care
April 1, 2014
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
Case Objectives
Appreciate that primary care doctors may be caring for an increasing number of patients wi…
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psnet.ahrq.gov/node/49663/psn-pdf
September 01, 2012 - Peripheral IV in Too Long
September 1, 2012
Fang C-T. Peripheral IV in Too Long. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/peripheral-iv-too-long
Case Objectives
Appreciate the complications associated with peripheral intravenous (IV) catheters.
Describe the optimal sterile technique that should be us…
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psnet.ahrq.gov/node/49498/psn-pdf
January 01, 2006 - An Ounce of Prevention
January 1, 2006
Kucher N. An Ounce of Prevention. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/ounce-prevention
Case Objectives
Assess risk for venous thromboembolism (VTE) in hospitalized patients
List recommended strategies for VTE prevention for various risk groups
Identify pat…
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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…
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/web-mm/ounce-prevention
February 17, 2011 - SPOTLIGHT CASE
An Ounce of Prevention
Citation Text:
Kucher N. An Ounce of Prevention. 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…
-
psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH
November 1, 2010
In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…
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psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
August 20, 2018 - Buprenorphine and the Medically Ill Patient
Citation Text:
McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX E…
-
psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - Advancing Patient Safety Through State Reporting
Systems
June 1, 2007
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
Perspective
Seven years ago, the Institute of Medicine (I…
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psnet.ahrq.gov/node/49437/psn-pdf
March 01, 2004 - Crossing the Line
March 1, 2004
Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/crossing-line
Case Objectives
Review complications of central venous catheterization
Discuss patient and operator factors that affect complication rates
Describe methods for preventing c…
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psnet.ahrq.gov/node/49672/psn-pdf
January 01, 2013 - The Lung Nodule That Refused To Grow
December 1, 2012
Balekian AA, Gould MK. The Lung Nodule That Refused To Grow. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/lung-nodule-refused-grow
Case Objectives
Define a solitary pulmonary nodule.
Identify the different initial first steps of management.
Identify …
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psnet.ahrq.gov/web-mm/failure-latch
November 27, 2012 - Failure to Latch
Citation Text:
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - PowerPoint Presentation
Spotlight
A Lot of Pain (Medications)
1
This presentation is based on the September 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…
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psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx
Spotlight
Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full …