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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
    January 01, 2022 - Spotlight Spotlight Delayed Diagnosis of Mesenteric Ischemia Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc o AHRQ WebM&M…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49506/psn-pdf
    March 01, 2006 - The Wet Read March 1, 2006 Arenson RL. The Wet Read. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/wet-read Case Objectives Appreciate the limitations of radiology resident emergency coverage. Understand the rate of discrepancy between radiology resident preliminary reads and attending radiologists' fina…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865540/psn-pdf
    April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration April 11, 2024 Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration The Case An 82-year-old woman presented to the Emergency Department (ED) for …
  4. psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
    March 01, 2011 - relatively poor, consisting of nine pre–post studies and only one randomized trial.( 10 ) No studies evaluated
  5. psnet.ahrq.gov/web-mm/finding-fault-default-alert
    August 28, 2024 - Finding Fault With the Default Alert Citation Text: Baysari M. Finding Fault With the Default Alert. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…
  6. psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
    May 01, 2011 - Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention Citation Text: Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Cop…
  7. psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
    February 01, 2014 - Wrong-Time Error With High-Alert Medication Citation Text: Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX…
  8. psnet.ahrq.gov/web-mm/40-k
    January 12, 2011 - 40 of K Citation Text: Lesar TS. 40 of K. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cita…
  9. psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
    November 25, 2020 - Misdiagnosis of a Pelvic Mass versus Pregnancy Citation Text: Leiserowitz GS, Herding H. Misdiagnosis of a Pelvic Mass versus Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google …
  10. psnet.ahrq.gov/web-mm/dropped-lung
    February 06, 2012 - The Dropped Lung Citation Text: Heffner JR. The Dropped Lung. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49458/psn-pdf
    September 01, 2004 - Poor Prognosis September 1, 2004 Lamont EB. Poor Prognosis. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/poor-prognosis Case Objectives Understand the current limitations of physicians' ability to provide prognoses. List the variables that can be used to guide treatment decisions and prognostication in e…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49605/psn-pdf
    June 01, 2010 - Acute Respiratory Arrest in Pregnancy June 1, 2010 Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy The Case A 35-year-old woman was 38 weeks pregnant with twins (G3P2). When she developed acute onset of shortness of breath an…
  13. psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
    February 28, 2024 - After the implementation, the impact will be evaluated at three- and six-month intervals.
  14. psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
    February 28, 2024 - After the implementation, the impact will be evaluated at three- and six-month intervals.
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73121/psn-pdf
    April 07, 2021 - The impact of introducing automated dispensing cabinets, barcode medication administration, and closed- loop electronic medication management systems on work processes and safety of controlled medications in hospitals: a systematic review. April 7, 2021 Zheng WY, Lichtner V, Van Dort BA, et al. The impact of intr…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41789/psn-pdf
    September 01, 2016 - Drug–drug interactions that should be non-interruptive in order to reduce alert fatigue in electronic health records. September 1, 2016 Phansalkar S, van der Sijs H, Tucker AD, et al. Drug-drug interactions that should be non-interruptive in order to reduce alert fatigue in electronic health records. J Am Med Infor…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47578/psn-pdf
    November 28, 2018 - Identifying electronic health record usability and safety challenges in pediatric settings. November 28, 2018 Ratwani RM, Savage E, Will A, et al. Identifying Electronic Health Record Usability And Safety Challenges In Pediatric Settings. Health Aff (Millwood). 2018;37(11):1752-1759. doi:10.1377/hlthaff.2018.0699. …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38120/psn-pdf
    June 16, 2011 - Organizational culture, team climate and diabetes care in small office-based practices. June 16, 2011 Bosch M, Dijkstra R, Wensing M, et al. Organizational culture, team climate and diabetes care in small office-based practices. BMC Health Serv Res. 2008;8:180. doi:10.1186/1472-6963-8-180. https://psnet.ahrq.gov/i…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38076/psn-pdf
    February 15, 2011 - Consequences of inadequate sign-out for patient care. February 15, 2011 Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168(16):1755-60. doi:10.1001/archinte.168.16.1755. https://psnet.ahrq.gov/issue/consequences-inadequate-sign-out-patient-care W…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847717/psn-pdf
    April 19, 2023 - Quality improvement initiative to decrease central line- associated bloodstream infections during the COVID-19 pandemic: a "zero harm" approach. April 19, 2023 Redstone CS, Zadeh M, Wilson M-A, et al. Quality improvement initiative to decrease central line- associated bloodstream infections during the COVID-19 pan…

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