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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…
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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…
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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 …
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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
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNot…
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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…
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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.
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Format:
Google Scholar BibTeX…
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Cita…
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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.
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Format:
Google …
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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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…
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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…
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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.
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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.
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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…
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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…
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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.
…
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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…
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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…
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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…