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psnet.ahrq.gov/node/49705/psn-pdf
January 01, 2020 - A "Reflexive" Diagnosis in Primary Care
April 1, 2014
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
Case Objectives
Appreciate that primary care doctors may be caring for an increasing number of patients wi…
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psnet.ahrq.gov/node/49663/psn-pdf
September 01, 2012 - Peripheral IV in Too Long
September 1, 2012
Fang C-T. Peripheral IV in Too Long. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/peripheral-iv-too-long
Case Objectives
Appreciate the complications associated with peripheral intravenous (IV) catheters.
Describe the optimal sterile technique that should be us…
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psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx
Spotlight
Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full …
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psnet.ahrq.gov/node/33774/psn-pdf
December 01, 2014 - In Conversation With… Edward Kelley, PhD
December 1, 2014
In Conversation With… Edward Kelley, PhD. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
Editor's note: Edward Kelley, PhD, is Director of Service Delivery and Safety for the World Health
Organization (WHO). He ha…
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - Tough Call: Addressing Errors From Previous Providers
March 1, 2014
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
Case Objectives
Define what it means to be a professional.
Identi…
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psnet.ahrq.gov/web-mm/breakage-picc-line
June 21, 2023 - SPOTLIGHT CASE
Breakage of a PICC Line
Citation Text:
Dimov V. Breakage of a PICC Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - Personal Health Literacy
Citation Text:
Bakerjian D. Personal Health Literacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
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psnet.ahrq.gov/web-mm/its-sarah-not-stephen
January 01, 2015 - SPOTLIGHT CASE
It's Sarah, Not Stephen!
Citation Text:
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNo…
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psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
May 11, 2019 - SPOTLIGHT CASE
The Consequences of Miscommunication Regarding a Possible Artifact
Citation Text:
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/node/49669/psn-pdf
November 01, 2012 - Transfusion Overload
November 1, 2012
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfusion-overload
Case Objectives
Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit
below 30% are not supported by the evidence.…
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose
Citation Text:
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/node/33714/psn-pdf
July 01, 2011 - In Conversation with…William B. Munier, MD, MBA
July 1, 2011
In Conversation with…William B. Munier, MD, MBA. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
Editor's note: William B. Munier, MD, MBA, is the Director of the Center for Quality Improvement and
Pati…
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psnet.ahrq.gov/node/44723/psn-pdf
December 16, 2015 - Situation, background, assessment, and
recommendation–guided huddles improve
communication and teamwork in the emergency
department.
December 16, 2015
Martin HA, Ciurzynski SM. Situation, Background, Assessment, and Recommendation-Guided Huddles
Improve Communication and Teamwork in the Emergency Department. Jour…
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psnet.ahrq.gov/node/38330/psn-pdf
September 24, 2010 - Medication safety teams' guided implementation of
electronic medication administration records in five
nursing homes.
September 24, 2010
Scott-Cawiezell J, Madsen RW, Pepper GA, et al. Medication safety teams' guided implementation of
electronic medication administration records in five nursing homes. Jt Comm J Qu…
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psnet.ahrq.gov/node/847730/psn-pdf
February 26, 2018 - “Brave men” and “emotional women”: a theory-guided
literature review on gender bias in health care and
gendered norms towards patients with chronic pain.
February 26, 2018
Samulowitz A, Gremyr I, Eriksson E, et al. “Brave men” and “emotional women”: a theory-guided literature
review on gender bias in health care a…
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psnet.ahrq.gov/node/39509/psn-pdf
August 08, 2010 - Bad stars or guiding lights? Learning from disasters to
improve patient safety.
August 8, 2010
Hughes C, Travaglia JF, Braithwaite J. Bad stars or guiding lights? Learning from disasters to improve
patient safety. Qual Saf Health Care. 2010;19(4):332-6. doi:10.1136/qshc.2008.030148.
https://psnet.ahrq.gov/issue/ba…
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psnet.ahrq.gov/node/36708/psn-pdf
April 21, 2011 - Missed breast cancers at US-guided core needle biopsy:
how to reduce them.
April 21, 2011
Youk JH, Kim E-K, Kim MJ, et al. Missed breast cancers at US-guided core needle biopsy: how to reduce
them. Radiographics. 2007;27(1):79-94.
https://psnet.ahrq.gov/issue/missed-breast-cancers-us-guided-core-needle-biopsy-how-…
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psnet.ahrq.gov/node/35009/psn-pdf
May 27, 2011 - Guided prescription of psychotropic medications for
geriatric inpatients.
May 27, 2011
Peterson JF, Kuperman GJ, Shek C, et al. Guided prescription of psychotropic medications for geriatric
inpatients. Arch Intern Med. 2005;165(7):802-7.
https://psnet.ahrq.gov/issue/guided-prescription-psychotropic-medications-ger…
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psnet.ahrq.gov/node/40764/psn-pdf
December 29, 2014 - Wristbands as aids to reduce misidentification: an
ethnographically guided task analysis.
December 29, 2014
Smith A, Casey K, Wilson J, et al. Wristbands as aids to reduce misidentification: an ethnographically
guided task analysis. Int J Qual Health Care. 2011;23(5):590-9. doi:10.1093/intqhc/mzr045.
https://psnet…
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psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
October 01, 2013 - March 20, 2019
Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era