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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking
January 26, 2022
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
Disclosure of Relevant Financial Relationships: As a provider ac…
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - Mismanagement of Delirium
Citation Text:
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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digital.ahrq.gov/sites/default/files/docs/publication/k08hs017951-rand-final-report-2015.pdf
January 01, 2015 - Using Health Information Technology to Improve Delivery of HPV Vaccine - Final Report
Program Director/Principal Investigator (Last, First, Middle): Rand, Cynthia M.
Title: Using Health Information Technology to Improve Delivery of HPV Vaccine
PI: Cynthia M. Rand…
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psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
March 15, 2023 - E-cigarette Explosion in a Patient Room
Citation Text:
Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/846915/psn-pdf
March 29, 2023 - Challenging Case of Multiple Suicide Attempts in a
Complex Patient with Psychiatric Comorbidities.
March 29, 2023
Bourgeois JA, Xiong G. Challenging Case of Multiple Suicide Attempts in a Complex Patient with
Psychiatric Comorbidities. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/challenging-case-multiple…
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - Implementing a Fall Prevention Program
Frances Healey, RN, PhD | December 1, 2011
View more articles from the same authors.
Citation Text:
Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
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psnet.ahrq.gov/node/49840/psn-pdf
September 01, 2018 - Steroids and Safety: Preventing Medication Adverse
Events During Transitions of Care
September 1, 2018
Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of
Care. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adver…
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psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
April 01, 2008 - Anticoagulation: Held Too Long
Citation Text:
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
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psnet.ahrq.gov/node/862983/psn-pdf
February 28, 2024 - Airway Obstruction during Anterior Cervical Spine
Surgery
February 28, 2024
Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
The Case
A 47-year-old obese man (body weight 13…
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
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psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - Triple Handoff
September 1, 2006
Vidyarthi A. Triple Handoff. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/triple-handoff
Case Objectives
Appreciate the prevalence of handoffs and sign out related errors.
Understand the key elements of a safe and effective written and verbal sign out.
List Kotter’s 8 st…
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psnet.ahrq.gov/node/49825/psn-pdf
April 01, 2018 - When Patients and Providers Speak Different Languages
April 1, 2018
Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
Case Objectives
Understand the legal and regulatory obligations to prov…
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - SPOTLIGHT CASE
Errors in Sepsis Management
Citation Text:
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/33764/psn-pdf
April 01, 2014 - In Conversation With… Tejal K. Gandhi, MD, MPH
April 1, 2014
In Conversation With… Tejal K. Gandhi, MD, MPH. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
Editor's note: Tejal K. Gandhi, MD, MPH, CPPS, is an Associate Professor of Medicine at Harvard
Medical School …
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psnet.ahrq.gov/node/33766/psn-pdf
May 01, 2014 - In Conversation With… Didier Pittet, MD, MS
May 1, 2014
In Conversation With… Didier Pittet, MD, MS. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
Editor's note: Didier Pittet, MD, MS, is Professor of Medicine and Director of the Infection Control
Programme and WHO Co…
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care
Source and Credits
• This presentation is based on the 2020 AHRQ WebM&M Spotlight
Case
○ See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD
○ Editor…
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psnet.ahrq.gov/node/863308/psn-pdf
February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in
Death During Endoscopy
February 28, 2024
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
The Case
A…
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psnet.ahrq.gov/node/49486/psn-pdf
August 21, 2005 - Impatient Inpatient Dosing
August 21, 2005
White RH. Impatient Inpatient Dosing. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
Case Objectives
Appreciate the challenges of initiating warfarin therapy in the hospitalized patient
Understand the fundamental pharmacology of warfarin…
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psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
June 15, 2024 - In Conversation With… Andrew Bindman, MD
November 1, 2016
Citation Text:
In Conversation With… Andrew Bindman, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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For…
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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - Duty to Disclose Someone Else's Error?
May 1, 2011
Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
Case Objectives
State the rationale for disclosing medical errors.
Describe key principles in effective error disclosure.
…