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psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - For example,
rather than asking, "Am I falling victim to premature closure in this case?"
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psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - March 8, 2023
Falling through the cracks: the invisible hospital cleaning workforce.
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - SPOTLIGHT CASE
Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations
Citation Text:
Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. PSNet [internet]. Rockville (MD): Agency for He…
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psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - Double Dosing, by the Rules
March 21, 2009
Cohen H. Double Dosing, by the Rules. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/double-dosing-rules
The Case
A 65-year-old woman with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) was
admitted to a medical unit during the night with wo…
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psnet.ahrq.gov/node/49520/psn-pdf
September 01, 2006 - DNR in the OR and Afterwards
September 1, 2006
Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
The Case
An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and
suffered a fractured femur. After initial eval…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.128_slideshow.ppt
July 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case July 2006
Moving Pains
Source and Credits
This presentation is based on the June/July 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Hildy Schell, RN, MS, CCRN, CCNS, and…
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psnet.ahrq.gov/node/867980/psn-pdf
March 25, 2025 - Not All Headaches are Due to Migraine: Red Flags, Don’t
Miss Diagnoses, and Diagnostic Pitfalls
March 25, 2025
Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic
Pitfalls. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-fla…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
December 01, 2010 - Spotlight Case July 2008
Spotlight Case
The Forgotten Turn
*
*
Source and Credits
This presentation is based on the December 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Susan Barbour, RN, FNP, University of California San Francisco …
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psnet.ahrq.gov/node/72737/psn-pdf
February 09, 2021 - Geisinger’s Outpatient Addiction Medicine Specialty
Program Uses Data-Driven Decision Making and MAT to
Reduce Mortality Rates
February 9, 2021
https://psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-
driven-decision
Summary
The team at Geisinger sought to develop a…
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psnet.ahrq.gov/primer/opioid-safety
December 15, 2024 - Opioid Safety
Citation Text:
Opioid Safety. 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
Download Ci…
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psnet.ahrq.gov/web-mm/informed-or-misled
April 24, 2018 - Informed or Misled?
Citation Text:
White SM. Informed or Misled?
. 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…
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - SPOTLIGHT CASE
Transfusion Thresholds in Gastrointestinal Bleeding
Citation Text:
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citati…
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psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
June 01, 2011 - In Conversation with… Edward Tenner, PhD
June 1, 2011
Also Read an Essay
Citation Text:
In Conversation with… Edward Tenner, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Cop…
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - Critical Echocardiogram Result Lost to Follow-up
Citation Text:
Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citation
Format:
Google Sch…
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - Number one, because there's a notion that this is not something that falls within our accountability.
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psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - communication had been significantly better than it was, there is always the chance of a key piece of data falling
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psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - emergency department (ED) from a nursing facility due to decreased oral intake, fevers, confusion, and falling
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psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
December 01, 2017 - Leads to Sepsis
October 1, 2016
WebM&M Cases
Falling
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psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
October 31, 2023 - Perspective
The Ongoing Journey to Prevent Patient Falls … In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - 28, 2023
Patient Safety Innovations
Preventing Falls