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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
    January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74713/psn-pdf
    January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking January 26, 2022 Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking Disclosure of Relevant Financial Relationships: As a provider ac…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33785/psn-pdf
    May 01, 2015 - In Conversation With… John D. Birkmeyer, MD May 1, 2015 In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md Editor's note: John D. Birkmeyer, MD, is an internationally recognized health services researcher with expertise in perfo…
  4. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
    January 01, 2020 - Spotlight Spotlight Some Patients Can’t Wait: Improving Timeliness of Emergency Department Care Source and Credits • This presentation is based on the 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm • Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD ○ Editor…
  5. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
    January 01, 2022 - Spotlight Spotlight Delayed Diagnosis of Mesenteric Ischemia Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc o AHRQ WebM&M…
  6. psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx Spotlight Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73300/psn-pdf
    July 01, 2022 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care May 26, 2021 https://psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care Summary The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs,…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74252/psn-pdf
    January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO January 12, 2022 In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33740/psn-pdf
    November 01, 2012 - In Conversation With… Abraham Verghese, MD November 1, 2012 In Conversation With… Abraham Verghese, MD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-abraham-verghese-md Editor's note: Abraham Verghese, MD, is Professor for the Theory and Practice of Medicine at the Stanford University S…
  10. psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
    October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 12, 2020 …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865411/psn-pdf
    March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy March 27, 2024 Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49474/psn-pdf
    March 01, 2005 - Hidden Mystery March 1, 2005 Brunette DD. Hidden Mystery. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/hidden-mystery Case Objectives Appreciate the challenges of caring for morbidly obese patients. List specific interventions that can be implemented when caring for obese patients. Develop a rational ap…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33837/psn-pdf
    July 01, 2017 - In Conversation With… Michelle Mello, MPhil, JD, PhD July 1, 2017 In Conversation With… Michelle Mello, MPhil, JD, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd Editor's note: Michelle Mello is Professor of Law at Stanford Law School and Professor of Healt…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49708/psn-pdf
    May 01, 2014 - Medication Reconciliation With a Twist (or Dare We Say, a Patch?) May 1, 2014 Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch Case Objectives Appreciate that medication discrepanc…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49861/psn-pdf
    May 01, 2019 - Updates in the Management of High-Risk Pulmonary Embolism May 1, 2019 Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism Case Objectives Review common risk factors, typical present…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33792/psn-pdf
    September 01, 2015 - In Conversation With… Eric J. Topol, MD September 1, 2015 In Conversation With… Eric J. Topol, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-eric-j-topol-md Editor's note: Eric J. Topol, MD, is Director of Scripps Translational Science Institute, Professor of Genomics at The Scripps …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49765/psn-pdf
    August 21, 2016 - Cognitive Overload in the ICU August 21, 2016 Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/cognitive-overload-icu Case Objectives Identify the role of cognitive overload—especially interruptions—in compromising quality of care and patient safety. List…
  18. psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
    February 01, 2023 - SPOTLIGHT CASE When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Citation Text: Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…
  19. psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
    October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. Citation Text: Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
  20. psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
    April 27, 2022 - Annual Perspective Patient Safety in the Ambulatory Care Setting August 5, 2022  View more articles from the same authors. Citation Text: Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. Rockville (MD): …

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