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  1. psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
    January 01, 2024 - Dangerous mechanism (i.e., pedestrian struck by motor vehicle, occupant ejected from motor vehicle, or fall
  2. psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
    April 03, 2024 - To date, such cost-benefit studies have tended to fall on the side of benefit.( 29,30 ) This case illustrates
  3. psnet.ahrq.gov/web-mm/see-patient-first
    September 27, 2023 - 2) activation of a code or rapid response, 3) a significant change in clinical status, 4) a patient fall
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837748/psn-pdf
    August 05, 2022 - readmitted 10 days later with another episode of severe hypoglycemia and a humeral fracture caused by a fall
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867357/psn-pdf
    December 18, 2024 - tube (ETT) placement was confirmed by auscultation of breath sounds and observation of chest rise and fall
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60856/psn-pdf
    August 26, 2020 - admitted to a major trauma center for a pathologic pelvic fracture (secondary to osteoporosis) after a fall
  7. psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
    October 01, 2004 - reporting hospital-specific mortality following coronary bypass surgery, mortality rates were observed to fall
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49806/psn-pdf
    September 01, 2017 - Failed Interpretation of Screening Tool: Delayed Treatment September 1, 2017 Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment The Case An 88-year-old man present…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49754/psn-pdf
    February 01, 2016 - Picking Up the Cause of the Stroke February 1, 2016 Chopra V. Picking Up the Cause of the Stroke. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/picking-cause-stroke The Case A 62-year-old man with poorly controlled diabetes was transferred to a tertiary care center from a community hospital for management…
  10. psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
    November 08, 2013 - Diffusion of Responsibility Leads to Danger Citation Text: Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar…
  11. psnet.ahrq.gov/clinical-areas
    March 24, 2025 - Clinical Areas Scroll down to search or browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nurse care or medical specialty, featured in the resources. Latest by Clinical Areas In Conversation with Edwin Boudreaux about S…
  12. psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
    August 21, 2007 - SPOTLIGHT CASE Wandering Off the Floors: Safety and Security Risks of Patient Wandering Citation Text: Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Huma…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49594/psn-pdf
    December 01, 2009 - Standard Deviations December 1, 2009 Sabin JE. Standard Deviations. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/standard-deviations Case Objectives Understand the safety risks associated with patients being discharged against medical advice (AMA). Recognize safety risks associated with being part of a …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33788/psn-pdf
    June 01, 2015 - In Conversation With… Christine Cassel, MD June 1, 2015 In Conversation With… Christine Cassel, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-christine-cassel-md Editor's note: Christine Cassel, MD, is President and CEO of the National Quality Forum (NQF). Dr. Cassel, one of the foun…
  15. psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
    October 19, 2022 - CYP450 Drugs: Expect the Unexpected Citation Text: Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49783/psn-pdf
    February 01, 2017 - The Hazards of Distraction: Ticking All the EHR Boxes February 1, 2017 Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes Case Objectives List the goals of having order sets in the electronic health record…
  17. psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
    October 30, 2024 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 14, 2023 Innov…
  18. psnet.ahrq.gov/web-mm/other-hand
    December 12, 2012 - On the Other Hand Citation Text: Henneman EA. On the Other Hand. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  19. psnet.ahrq.gov/web-mm/poor-prognosis
    March 15, 2016 - SPOTLIGHT CASE Poor Prognosis Citation Text: Lamont EB. Poor Prognosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
  20. psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
    March 21, 2009 - A Mistaken Dose of Naloxone  Citation Text: Cutler E, Gunawardena D. A Mistaken Dose of Naloxone . 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 …

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