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psnet.ahrq.gov/web-mm/transfusion-slip
June 14, 2011 - Transfusion "Slip"
Citation Text:
Kaplan HS. Transfusion "Slip". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - The Forgotten Med
Citation Text:
Cucina R. The Forgotten Med. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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…
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psnet.ahrq.gov/web-mm/premature-or-overdue
December 23, 2020 - Premature or Overdue?
Citation Text:
Thomas J, Hannah M. Premature or Overdue?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/49794/psn-pdf
May 01, 2017 - Communication Error in a Closed ICU
May 1, 2017
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/communication-error-closed-icu
The Case
A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney
transplant), co…
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - Low on the Totem Pole
December 1, 2005
Wachter R. Low on the Totem Pole. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/low-totem-pole
Case Objectives
Understand the concept of authority gradient
List steps that can be taken to increase communication across an authority gradient
Consider the current cultu…
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psnet.ahrq.gov/node/33660/psn-pdf
December 01, 2007 - In Conversation with...Eric Coleman, MD, MPH
December 1, 2007
In Conversation with..Eric Coleman, MD, MPH. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
Editor's Note: Eric A. Coleman, MD, MPH, is Associate Professor of Medicine at the University of
Colorado. Train…
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psnet.ahrq.gov/node/33691/psn-pdf
December 01, 2009 - How to Identify and Manage Problem Behaviors
December 1, 2009
Rosenstein AH, O'Daniel M. How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
Perspective
The 1999 Institute of Medicine report highlighted the need for heal…
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psnet.ahrq.gov/web-mm/two-pills-same-drug
May 27, 2011 - Two Pills, Same Drug
Citation Text:
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple
Health System Vulnerabilities
May 26, 2021
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health
System Vulnerabilities. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…
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psnet.ahrq.gov/node/851555/psn-pdf
July 31, 2023 - Bandemia as a Harbinger of Stercoral Colitis and
Impending Perforation
July 31, 2023
Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
The Case
A 56-year-…
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psnet.ahrq.gov/node/33697/psn-pdf
June 01, 2010 - What Do We Know About Emergency Department Safety?
June 1, 2010
Sklar DP, Crandall CS. What Do We Know About Emergency Department Safety? PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
Perspective
Emergency medicine has evolved from a location, with var…
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psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
November 21, 2021 - Lapse in Antibiotics Leads to Sepsis
Citation Text:
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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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/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
December 18, 2019 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences
Citation Text:
Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…
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psnet.ahrq.gov/node/49706/psn-pdf
January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication
Access Issue
April 1, 2014
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
The Case
A 24-year-old wom…
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psnet.ahrq.gov/node/50696/psn-pdf
November 27, 2019 - Complications of Vascular Access Procedures in Patients
with Kidney Disease
November 27, 2019
Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
The Ca…
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - Abnormal Volunteer Results
Citation Text:
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.350_slideshow.ppt
June 01, 2015 - PowerPoint Presentation
Spotlight
Anchoring Bias With Critical Implications
1
This presentation is based on the June 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Edward Etchells, MD, MSc, Division of General Internal Medicine, Centre for Q…
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psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-home-residents
July 23, 2024 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents
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July 28, 2021
Innovation
Contact
…
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psnet.ahrq.gov/node/73998/psn-pdf
October 27, 2021 - The Hidden Danger of Unseen Intravenous Catheters
October 27, 2021
Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
The Case
A 6-week-old infant underwent a craniotomy and excision of abnormal bra…