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psnet.ahrq.gov/web-mm/departure-central-line-ritual
October 13, 2018 - Departure From Central Line Ritual
Citation Text:
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. 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/fire-hole-or-fire
August 03, 2017 - Fire in the Hole!—An OR Fire
Citation Text:
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. 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/reconciling-doses
August 14, 2017 - SPOTLIGHT CASE
Reconciling Doses
Citation Text:
Federico F. Reconciling Doses. 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/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/returning-home-safely
December 22, 2018 - Returning Home Safely
Citation Text:
Toles M. Returning Home Safely. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - Are You Mrs. A? An Issue of Identification Over Telephone
Citation Text:
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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…
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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac
Arrest
September 30, 2020
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
Disclosure of Relevant Financial Relationships: As a pr…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.152_slideshow.ppt
June 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case June 2007
Beeline to Spine
Source and Credits
This presentation is based on June 2007
AHRQ WebM&M Spotlight Case
See full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Gerald W. Smetana, MD, Harvard Medical School, Beth Israel D…
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psnet.ahrq.gov/node/49627/psn-pdf
June 01, 2011 - The ECG Is Not Normal
June 1, 2011
Zuger A. The ECG Is Not Normal. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/ecg-not-normal
Case Objectives
State how frequently physicians care for family or relatives.
Describe the risks associated with caring for family members or relatives.
Appreciate some of the s…
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psnet.ahrq.gov/node/865984/psn-pdf
May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain
with Elevated D-dimer.
May 29, 2024
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-
dimer. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d…
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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…
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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 …
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - Around the Block
Citation Text:
Minichiello T. Around the Block. 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/49664/psn-pdf
January 01, 2013 - Empty Handoff
September 1, 2012
Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/empty-handoff
The Case
A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a
leg wound. The patient's medical history included chronic…
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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…
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psnet.ahrq.gov/node/33743/psn-pdf
December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing
and Treating Delirium in the Intensive Care Unit
December 1, 2012
Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating
Delirium in the Intensive Care Unit. PSNet [internet]. 2012.
https://psnet.ahrq.gov…
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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…
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psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - Slippery Slide Into Life
December 1, 2005
Halamek LP. Slippery Slide Into Life. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/slippery-slide-life
The Case
A 25-year-old woman presented to the hospital in labor and at full gestation after receiving uncomplicated
prenatal care. A third-year obstetrics and g…
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psnet.ahrq.gov/web-mm/too-much-too-fast
June 14, 2019 - Too Much, Too Fast
Citation Text:
Tuot D. Too Much, Too Fast. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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…
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psnet.ahrq.gov/node/49795/psn-pdf
June 01, 2017 - The Perils of Contrast Media
June 1, 2017
Sadat U, Solomon R. The Perils of Contrast Media. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/perils-contrast-media
Case Objectives
Recognize that contrast media are potentially nephrotoxic.
Identify key risk factors for the development of contrast-induced kidne…