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psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - Miscarriage
June 1, 2003
WebM&M Cases
Another Fall
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psnet.ahrq.gov/node/33771/psn-pdf
August 22, 2014 - Every outpatient clinical setting needs to
have active tracking systems for things that we know can fall
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psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - while being cared for in a health care facility
Patient death or serious disability associated with a fall
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psnet.ahrq.gov/node/49690/psn-pdf
September 01, 2013 - Patients with
concurrent substance abuse and high risk for abusing the prescription opiates fall under
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psnet.ahrq.gov/web-mm/lost-transition
November 17, 2010 - Catastrophe requires multiple failures—a single point failure is not enough.”( 14 ) Communication failures fall
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psnet.ahrq.gov/web-mm/hidden-mystery
December 01, 2011 - behavior.( 19 ) Taken together, these studies indicate that obese patients' medical care might well fall
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - provider is unavailable or distracted, creating opportunities for critical pieces of information to fall
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - Since the creation of our sepsis team in fall 2012, our inpatient bundle compliance has increased from
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psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
June 24, 2020 - 20 hours before there is any significant change in the INR (because factor VII levels first have to fall
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - January 1, 2004
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
November 16, 2022 - the second study, more detailed intervention components and descriptions were established which all fall
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psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - April 3, 2013
Perspective
Implementing a Fall Prevention
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psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - Getting the Diagnosis Both Right and Wrong
September 25, 2019
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
The Case
A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…
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psnet.ahrq.gov/node/49529/psn-pdf
February 01, 2007 - Crossed Coverage
February 1, 2007
Kayser SR. Crossed Coverage. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/crossed-coverage
The Case
A 27-year-old woman with a history of congenital heart disease was admitted for cardiac transplantation
evaluation. She had already undergone multiple surgeries, including…
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psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - Glucose Roller Coaster
Citation Text:
Sharpe B. Glucose Roller Coaster. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - Baffled by Botulinum Toxin
Citation Text:
Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
March 26, 2015 - Right Place, Right Drug, Wrong Strength
Citation Text:
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/49583/psn-pdf
April 01, 2009 - Eptifibatide Epilogue
April 1, 2009
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue
The Case
A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute
coronary syndrome. Serial testing for mark…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
September 01, 2016 - PowerPoint Presentation
Spotlight
A Pill Organizing Plight
*
Source and Credits
This presentation is based on the September 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Ro…
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psnet.ahrq.gov/web-mm/bleeding-risk
November 01, 2003 - Bleeding Risk
Citation Text:
Crowther MA. Bleeding Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…