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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - SPOTLIGHT CASE
A Weighty Mistake
Citation Text:
Bokser SJ. A Weighty Mistake. 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 EndNote 7 XML Endn…
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psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
November 16, 2022 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.
Citation Text:
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.. PSNet [inter…
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking
January 26, 2022
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
Disclosure of Relevant Financial Relationships: As a provider ac…
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Patient Safety Events Involving Opioid
Dose Stacking
Source and Credits
• This presentation is based on the January 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: Hollie Porras, PharmD, BCPS and Cathy Lammers…
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psnet.ahrq.gov/node/73103/psn-pdf
March 31, 2021 - Delayed Diagnosis in the Setting of Virtual Care:
Remembering the Physical Examination
March 31, 2021
Valdes W, Utter GH. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical
Examination. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-…
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psnet.ahrq.gov/web-mm/hidden-mystery
December 01, 2011 - SPOTLIGHT CASE
Hidden Mystery
Citation Text:
Brunette DD. Hidden Mystery. 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/web-mm/e-cigarette-explosion-patient-room
March 15, 2023 - E-cigarette Explosion in a Patient Room
Citation Text:
Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
August 01, 2005 - The Unfinished Patient Safety Agenda
Linda H. Aiken, PhD, RN | August 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Aiken LH. The Unfinished Patient Safety Agenda. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/node/49822/psn-pdf
March 01, 2018 - Isolated Clot, Real Error
March 1, 2018
Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/isolated-clot-real-error
Case Objectives
Appreciate that errors are common in the management of venous thromboembolism disease.
Describe patients with venous thromboembolism i…
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
April 19, 2023 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
Citation Text:
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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…
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psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing
October 30, 2019
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
Case Objectives
List the most common errors associated with computerized…
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psnet.ahrq.gov/node/33765/psn-pdf
April 01, 2014 - In Conversation With… Leah Binder, MA, MGA
April 1, 2014
In Conversation With… Leah Binder, MA, MGA. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga
Editor's note: Leah Binder is President and CEO of The Leapfrog Group, a national nonprofit
representing employers and oth…
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - Missed CANDOR Implementation Opportunities.
November 16, 2022
Schweitzer L. Missed CANDOR Implementation Opportunities. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
The Case
A 58-year-old man with a history of type 2 diabetes mellitus, hypertension, morbid obesit…
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psnet.ahrq.gov/node/33879/psn-pdf
May 01, 2019 - In Conversation With… Jane Brice, MD, MPH
May 1, 2019
In Conversation With… Jane Brice, MD, MPH. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
Editor's note: Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University
of North Carolina. She…
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psnet.ahrq.gov/node/49486/psn-pdf
August 21, 2005 - Impatient Inpatient Dosing
August 21, 2005
White RH. Impatient Inpatient Dosing. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
Case Objectives
Appreciate the challenges of initiating warfarin therapy in the hospitalized patient
Understand the fundamental pharmacology of warfarin…
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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/49618/psn-pdf
February 01, 2011 - One Toxic Drug Is Not Like Another
February 1, 2011
Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
Case Objectives
Distinguish between the three distinct regulatory processes of board certification, medical licensure,
and credential…
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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions
April 28, 2021
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
The Case
A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and
severe e…
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psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse
Outcomes
July 8, 2022
Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
The Cases
Case 1: A 64-year-old man came in for a routine bron…