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  1. psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
    May 19, 2021 - Hyperglycemia and Switching to Subcutaneous Insulin Citation Text: Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Sc…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33703/psn-pdf
    November 01, 2010 - Are We Getting Better at Measuring Patient Safety? November 1, 2010 Rosen AK. Are We Getting Better at Measuring Patient Safety? PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety Perspective The past decade has witnessed unprecedented interest in patient safe…
  3. psnet.ahrq.gov/web-mm/empty-handoff
    August 01, 2017 - Empty Handoff Citation Text: Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49600/psn-pdf
    April 01, 2010 - Bad Writing, Wrong Medication April 1, 2010 Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication Case Objectives Differentiate between a medication error and an adverse drug event. Appreciate the system complexities involved in medication erro…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854897/psn-pdf
    October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose October 31, 2023 Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/weight-and-…
  6. psnet.ahrq.gov/web-mm/perils-contrast-media
    March 01, 2007 - SPOTLIGHT CASE The Perils of Contrast Media Citation Text: Sadat U, Solomon R. The Perils of Contrast Media. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX En…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33678/psn-pdf
    January 01, 2009 - In Conversation with…Thomas H. Gallagher, MD January 1, 2009 In Conversation with…Thomas H. Gallagher, MD. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md Editor's note: Thomas H. Gallagher, MD, is Associate Professor in the Department of Medicine and the Departme…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49639/psn-pdf
    November 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49712/psn-pdf
    June 01, 2014 - May I Have Another?—Medication Error June 1, 2014 Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error The Case A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a pharmacology-tra…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49741/psn-pdf
    September 01, 2015 - Abdominal Pain in Early Pregnancy September 1, 2015 Kilpatrick CC. Abdominal Pain in Early Pregnancy. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy Case Objectives Recognize when nausea and vomiting in pregnancy is abnormal. Identify the most common causes of non-obstetric a…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33814/psn-pdf
    September 01, 2016 - In Conversation With… Reed V. Tuckson, MD September 1, 2016 In Conversation With… Reed V. Tuckson, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md Editor's note: Dr. Tuckson is Managing Director of Tuckson Health Connections, LLC, and President of the American Telemed…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33718/psn-pdf
    October 01, 2011 - In Conversation With… Paul G. Shekelle, MD, MPH, PhD October 1, 2011 In Conversation With… Paul G. Shekelle, MD, MPH, PhD. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd Editor's note: Dr. Shekelle is director of the Southern California Evidence-Based Practice Cen…
  13. psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx Spotlight Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the ful…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60857/psn-pdf
    August 26, 2020 - Nothing Called Small Surgery August 26, 2020 Manske C. Nothing Called Small Surgery. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/nothing-called-small-surgery The Case  A 56-year-old female presented to surgical clinic with pain and swelling in left great toe associated with progressive deformity of the …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49798/psn-pdf
    July 01, 2017 - Pseudo-obstruction But a Real Perforation July 1, 2017 Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation Case Objectives Recognize acute colonic pseudo-obstruction and implement a medical management plan. Ide…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49859/psn-pdf
    April 01, 2019 - E-cigarette Explosion in a Patient Room April 1, 2019 Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room The Case A 49-year-old woman was admitted for an exacerbation of chronic obstructive pulmonary disease (COPD) without…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33635/psn-pdf
    July 01, 2006 - In Conversation with...Allan Frankel, MD July 1, 2006 In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this kind of work. Dr. Allan …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49645/psn-pdf
    February 01, 2012 - E-prescribing: E for error? February 1, 2012 Ashton EW. E-prescribing: E for error? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/e-prescribing-e-error Case Objectives Define e-prescribing. Describe ways in which e-prescribing can reduce health care costs. State how commonly prescription errors occur wit…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49828/psn-pdf
    May 01, 2018 - Out of Sight, Out of Mind: Out-of-Office Test Result Management May 1, 2018 Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management Case Objectives Recognize the general responsibilities of…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49699/psn-pdf
    February 01, 2014 - Multifactorial Medication Mishap February 1, 2014 Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap Case Objectives Understand the system-based causes of medication errors. Describe a model for a systems approach to error analysis. Id…

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