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  1. Diagnostic Errors | PSNet

    psnet.ahrq.gov/primer/diagnostic-errors
    June 15, 2024 - Diagnostic Errors Citation Text: Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33570/psn-pdf
    June 15, 2024 - Diagnostic Errors June 15, 2024 Diagnostic Errors. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/diagnostic-errors 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 20…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836812/psn-pdf
    March 30, 2022 - Strategies and Approaches for Investigating Patient Safety Events March 30, 2022 Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events Background This primer provides a broad …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851869/psn-pdf
    July 31, 2023 - Building Capacity for Patient Safety July 31, 2023 Hoffman R, Mossburg S, Van CM. Building Capacity for Patient Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/building-capacity-patient-safety In its 2019 report, Safer Together: A National Action Plan to Advance Patient Safety, the National Steer…

  5. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
    October 01, 2008 - Spotlight Case July 2008 Spotlight Case Recurrent Hypoglycemia: A Care Transition Failure? * * Source and Credits This presentation is based on the October 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Ted Eytan, MD, MS, MPH Editor, …

  6. Delirium or Dementia? | PSNet

    psnet.ahrq.gov/web-mm/delirium-or-dementia
    September 27, 2023 - SPOTLIGHT CASE Delirium or Dementia? Citation Text: Rudolph JL. Delirium or Dementia?. 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…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865413/psn-pdf
    March 27, 2024 - In Conversation with...Barbara Pelletreau and John Riggi about Cybersecurity March 27, 2024 Pelletreau B, Riggi J. In Conversation with..Barbara Pelletreau and John Riggi about Cybersecurity. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cyberse…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49525/psn-pdf
    December 01, 2006 - Hidden Heparins: HIT Happens December 1, 2006 Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens Case Objectives Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication, thrombosis. Discuss the managem…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49681/psn-pdf
    April 01, 2013 - Total Parenteral Nutrition, Multifarious Errors April 1, 2013 Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors Case Objectives Define parenteral nutrition (PN). Describe the PN-use process. Identify …

  10. Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
    January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx Spotlight A Loss of Trust and a Missed Diagnosis Source and Credits • This presentation is based on the February 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49737/psn-pdf
    June 01, 2015 - Unseen Perils of Urinary Catheters June 1, 2015 Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters The Case A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49591/psn-pdf
    October 01, 2009 - Difficult Encounters: A CMO and CNO Respond October 1, 2009 Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond Case Objectives Appreciate the risk of disruptive behavior and understand institutional respons…

  13. Medication Reconciliation With a Twist (or Dare We Say, a Patch?) | PSNet

    psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
    April 03, 2024 - SPOTLIGHT CASE Medication Reconciliation With a Twist (or Dare We Say, a Patch?) Citation Text: Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49717/psn-pdf
    September 01, 2014 - A Lot of Pain (Medications) September 1, 2014 Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/lot-pain-medications Case Objectives Appreciate the challenges of managing acute pain in hospitalized patients on chronic opioids. Describe the importance of understanding th…

  15. Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx Spotlight Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation Source and Credits • This presentation is based on the March 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857258/psn-pdf
    November 30, 2023 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon November 30, 2023 Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/always-check-muscle-twitch-…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33833/psn-pdf
    May 01, 2017 - In Conversation With… David Juurlink, MD, PhD May 1, 2017 In Conversation With… David Juurlink, MD, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd Editor's note: Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of Toronto, w…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33688/psn-pdf
    October 01, 2009 - In Conversation with... Charles Ornstein October 1, 2009 In Conversation with.. Charles Ornstein . PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-charles-ornstein Editor's note: Charles Ornstein is a senior reporter at ProPublica, a nonprofit news organization in New York. Formerly with th…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33831/psn-pdf
    April 01, 2017 - In Conversation With… Mark Chassin, MD, MPP, MPH April 1, 2017 In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph Editor's note: Dr. Chassin is president and chief executive officer of The Joint Commission. He is also p…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861760/psn-pdf
    January 31, 2024 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery January 31, 2024 Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…
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