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psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 2024 - SPOTLIGHT CASE
Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head
Citation Text:
Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
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psnet.ahrq.gov/web-mm/managing-care-challenges-group-home-setting-staffing-adequate-unplanned-incidents
April 27, 2022 - Unfortunately, the resident had another incontinence episode just as the CNA was getting her dressed.
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - of a videolaryngoscope and a
fiberscope may have prevented dental damage as well as the prolonged episode
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psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
January 01, 2020 - — In some circumstances, depending on the severity of the mental
illness/episode or developmental
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - During the latter episode, she developed signs suggestive of a transfusion reaction, which may represent
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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication
Citation Text:
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Cit…
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psnet.ahrq.gov/node/33824/psn-pdf
January 01, 2016 - Patient Safety and Opioid Medications
January 1, 2016
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
Annual Perspective 2016
Opioid medications confer significant risks of harm, including overdose death …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
August 01, 2015 - PowerPoint Presentation
Spotlight
Privacy or Safety?
1
This presentation is based on the July/August 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John D. Halamka, MD, MS, Beth Israel Deaconess Medical Center; and Deven McGraw, JD, MPH, LLM…
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psnet.ahrq.gov/node/49577/psn-pdf
January 01, 2009 - Are Two Insulin Pumps Better Than One?
January 1, 2009
Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one
The Case
A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass
graft surge…
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psnet.ahrq.gov/node/33815/psn-pdf
September 01, 2016 - Telemedicine and Patient Safety
September 1, 2016
Agboola SO, Kvedar JC. Telemedicine and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
Perspective
A paradigm shift is ongoing in the health care sector. The traditional model of episodic and hospital-base…
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psnet.ahrq.gov/node/49669/psn-pdf
November 01, 2012 - She remained in the hospital for 2 more weeks recovering from the episode and was
transferred back to
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psnet.ahrq.gov/node/49627/psn-pdf
June 01, 2011 - immediately from the
indecipherable squiggles of the cardiogram to the name on the tracing and the entire episode
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psnet.ahrq.gov/node/49816/psn-pdf
January 01, 2018 - Prior to this episode, she had been taking naltrexone to treat her alcohol use disorder and had
been
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psnet.ahrq.gov/node/33660/psn-pdf
December 01, 2007 - thinking I was seeing a patient coming in for follow-up, only for them to
berate me about the terrible episode
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psnet.ahrq.gov/node/33670/psn-pdf
July 01, 2008 - The patient did not
succumb to this, but it could have been a lethal episode.
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psnet.ahrq.gov/node/49602/psn-pdf
April 01, 2010 - Extended
oral anticoagulant therapy after a first episode of pulmonary embolism.
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - SPOTLIGHT CASE
Spotlight: Mistaken Attribution, Diagnostic Misstep
Citation Text:
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citat…
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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - The case prompted a formal review as, in addition to the preventable episode of hypoglycemia, the initiation
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Patient Safety 101
June 16, 2024
Patient Safety 101. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-safety-101
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in…
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psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
September 01, 2016 - complying with often complex therapeutic regimens, and maximally restoring their health after an illness episode