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psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
October 01, 2018 - CVC Removal: A Procedure Like Any Other
Citation Text:
Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/missed-pneumonia
June 01, 2005 - Missed Pneumonia
Citation Text:
Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
January 19, 2016 - Bowel Injury After Laparoscopic Surgery
Citation Text:
Moorthy K. Bowel Injury After Laparoscopic Surgery. 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/33614/psn-pdf
June 01, 2005 - Interpreting the Patient Safety Literature
June 1, 2005
Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
Perspective
Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…
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psnet.ahrq.gov/web-mm/round-trip-service
April 26, 2023 - Round-Trip Service
Citation Text:
McGrath MH. Round-Trip Service. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/case-patient-flow-management
February 23, 2019 - The Case for Patient Flow Management
Citation Text:
Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/49545/psn-pdf
September 01, 2007 - Coming Undone: Failure of Closure Device
September 1, 2007
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
The Case
A 65-year-old man underwent coronary angiography because of atypical exertional chest…
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psnet.ahrq.gov/node/49440/psn-pdf
March 01, 2004 - Autopsy Revelation
March 1, 2004
Shojania KG. Autopsy Revelation. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/autopsy-revelation
The Case
A 45-year-old male with development delay presented to the emergency department with acute abdominal
pain. His mother, who was his main caregiver, accompanied him. Th…
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psnet.ahrq.gov/node/49411/psn-pdf
July 01, 2003 - Code Status Confusion
July 1, 2003
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/code-status-confusion
Case Objectives
Appreciate challenges of determining goals of care in hospitalized patients
Understand patients’ common misconceptions about CPR
List typical mist…
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psnet.ahrq.gov/node/33622/psn-pdf
November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP
November 1, 2005
In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
Editor's Note: Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare
I…
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psnet.ahrq.gov/node/857260/psn-pdf
November 30, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP
(Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
November 30, 2023
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2
Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/when…
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - Pathologic Mistake
Citation Text:
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.176_slideshow.ppt
May 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case May 2008
Diagnosing HIV: It Doesn’t Take a Brain Surgeon
Source and Credits
This presentation is based on the May 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Roger Chou, MD, Oregon Health &…
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psnet.ahrq.gov/node/49643/psn-pdf
December 01, 2011 - More Treatment—Better Care?
December 1, 2011
Redberg R. More Treatment—Better Care? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/more-treatment-better-care
The Case
The patient is a 27-year-old female who presented to a 250-bed community hospital with numbness and
tingling of her hands and feet. She was …
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psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
February 10, 2010 - Residual Anesthesia: Tepid Burn
Citation Text:
Kurrek MM, Twersky RS. Residual Anesthesia: Tepid Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room
Citation Text:
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
January 31, 2020 - Annual Perspective
Updates in the Role of Health IT in Patient Safety
February 21, 2020
View more articles from the same authors.
Citation Text:
Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. Rockville …
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psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
October 30, 2024 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration
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June 14, 2023
Innov…
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psnet.ahrq.gov/web-mm/miscalculated-risk
March 01, 2015 - Miscalculated Risk
Citation Text:
Strassels SA. Miscalculated Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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