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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49857/psn-pdf
    March 01, 2019 - Duplicate Insulin Order March 1, 2019 Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/duplicate-insulin-order The Case A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency department (ED) for complaints of letharg…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49552/psn-pdf
    January 01, 2008 - How Do Providers Recover From Errors? January 1, 2008 West CP. How Do Providers Recover From Errors? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors Case Objectives Describe the provider-specific prevalence of medical errors. Appreciate the impact of medical errors on care pr…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73455/psn-pdf
    June 30, 2021 - Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks June 30, 2021 Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks The Case At the…

  4. Coming Undone: Failure of Closure Device | PSNet

    psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
    April 01, 2006 - Coming Undone: Failure of Closure Device Citation Text: Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar Bi…

  5. Resuscitation Errors: A Shocking Problem | PSNet

    psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
    October 19, 2022 - SPOTLIGHT CASE Resuscitation Errors: A Shocking Problem Citation Text: Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: …

  6. Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx (pdf file)

    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…

  7. Autopsy Revelation | PSNet

    psnet.ahrq.gov/web-mm/autopsy-revelation
    December 01, 2007 - Autopsy Revelation Citation Text: Shojania KG. Autopsy Revelation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

  8. Clostridium Difficile Relapse Secondary to Medication Access Issue | PSNet

    psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
    October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue Citation Text: Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Cit…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847934/psn-pdf
    April 26, 2023 - Patient Safety Indicators April 26, 2023 Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/patient-safety-indicators Background Over the past 25 years, policymakers and providers, payers, and purchasers of health care have increasingly focused attention on pati…

  10. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! | PSNet

    psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
    February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! Citation Text: 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]. Rockville (MD): Agency for Healthcar…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33877/psn-pdf
    April 01, 2019 - In Conversation With… Timothy B. McDonald, MD, JD April 1, 2019 In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd Editor's note: Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar…

  12. Who Nose Where the Airway Is? | PSNet

    psnet.ahrq.gov/web-mm/who-nose-where-airway
    May 01, 2016 - Who Nose Where the Airway Is? Citation Text: Lee CR. Who Nose Where the Airway Is?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

  13. Psn-Pdf (pdf file)

    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…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49669/psn-pdf
    November 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.…

  15. Spotlight Nstemi (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-07/spotlight_nstemi.pdf
    January 01, 2020 - Spotlight The NSTEMI Curbside Consultation Source and Credits • This presentation is based on the July 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Amparo C. Villablanca, MD and Gordon Wong, MD MBA o AHRQ WebM&M Editors …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860050/psn-pdf
    January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic Infant. January 4, 2024 Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant The Case A 2-month-old full-term male infant was b…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848109/psn-pdf
    April 26, 2023 - The Danger of 10% Intravenous Calcium Chloride Extravasation. April 26, 2023 The Danger of 10% Intravenous Calcium Chloride Extravasation. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation The Case A 52-year-old man with a history of lymphoplasmacytic lymph…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49543/psn-pdf
    September 01, 2007 - Medication Reconciliation: Whose Job Is It? September 1, 2007 Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it Case Objectives Appreciate the prevalence and impact of medication discrepancies at times of transition in …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49799/psn-pdf
    July 01, 2017 - Delayed Recognition of a Positive Blood Culture July 1, 2017 Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture The Case A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49531/psn-pdf
    March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…
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