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  1. psnet.ahrq.gov/issue/engaging-patients-medication-reconciliation-patient-portal-following-hospital-discharge
    February 03, 2011 - Study Engaging patients in medication reconciliation via a patient portal following hospital discharge. Citation Text: Heyworth L, Paquin AM, Clark J, et al. Engaging patients in medication reconciliation via a patient portal following hospital discharge. J Am Med Inform Assoc. 2014;21(e…
  2. psnet.ahrq.gov/issue/patient-safety-and-telephone-medicine-some-lessons-closed-claim-case-review
    May 18, 2022 - Study Patient safety and telephone medicine: some lessons from closed claim case review. Citation Text: Katz HP, Kaltsounis D, Halloran L, et al. Patient safety and telephone medicine : some lessons from closed claim case review. J Gen Intern Med. 2008;23(5):517-22. doi:10.1007/s11606-…
  3. psnet.ahrq.gov/issue/effect-hospital-multifaceted-clinical-pharmacist-intervention-risk-readmission-randomized
    September 13, 2023 - Study Classic Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission: a randomized clinical trial. Citation Text: Ravn-Nielsen LV, Duckert M-L, Lund ML, et al. Effect of an In-Hospital Multifaceted Clinical Pharmacist I…
  4. psnet.ahrq.gov/issue/clinical-decision-support-systems-could-be-modified-reduce-alert-fatigue-while-still
    December 21, 2022 - Commentary Clinical decision support systems could be modified to reduce 'alert fatigue' while still minimizing the risk of litigation. Citation Text: Kesselheim AS, Cresswell K, Phansalkar S, et al. Clinical decision support systems could be modified to reduce 'alert fatigue' while stil…
  5. psnet.ahrq.gov/issue/clinical-reasoning-education-us-medical-schools-results-national-survey-internal-medicine
    October 12, 2022 - Study Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors. Citation Text: Rencic J, Trowbridge RL, Fagan M, et al. Clinical Reasoning Education at US Medical Schools: Results from a National Survey of Internal Medici…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49719/psn-pdf
    September 01, 2014 - No BP During NIBP September 1, 2014 Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/no-bp-during-nibp The Case An otherwise healthy 49-year-old man with atrial fibrillation was scheduled for ablation in the catheterization laboratory under general endotracheal anes…
  7. psnet.ahrq.gov/web-mm/outbreak
    January 29, 2015 - Outbreak Citation Text: Rothman R, Stapleton S. Outbreak. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.368_slideshow.ppt
    February 01, 2016 - PowerPoint Presentation Spotlight Robotic Surgery: Risks vs. Rewards 1 Source and Credits This presentation is based on the February 2016 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Tara Kirkpatrick, MD, and Chad LaGrange, MD, Univer…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49731/psn-pdf
    April 01, 2015 - Fire in the Hole!—An OR Fire April 1, 2015 Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fire-hole-or-fire The Case A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinom…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49835/psn-pdf
    January 01, 2020 - Don't Pick the PICC July 1, 2018 McGill RL. Don't Pick the PICC. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/dont-pick-picc The Case A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy; glaucoma; and stage IV chronic kidney disease was admitted to the hospita…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49670/psn-pdf
    November 01, 2012 - Missed Pneumonia November 1, 2012 Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/missed-pneumonia The Case A 32-year-old man presented to the emergency department (ED) with 3 days of fever and right pleuritic chest pain. Review of systems was negative for cough or dy…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49823/psn-pdf
    March 01, 2018 - Shortcuts to Acetaminophen-induced Liver Failure March 1, 2018 Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure The Case An 18-year-old woman, 27 weeks pregnant, presented to the emergency dep…
  13. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.85_slideshow.ppt
    March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Douglas D. Br…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49641/psn-pdf
    November 01, 2011 - Liver Failure After Chemotherapy: Did We Forget Something? November 1, 2011 Lubel J. Liver Failure After Chemotherapy: Did We Forget Something? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something The Case A 51-year-old Cantonese-speaking female with a his…
  15. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.88_slideshow.ppt
    March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Douglas D. Br…
  16. psnet.ahrq.gov/periodic-issue/periodic-issue-472
    February 26, 2025 - February 26, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, repor…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33699/psn-pdf
    August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers August 1, 2010 Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers Perspective Academic medical…
  18. psnet.ahrq.gov/web-mm/dangerous-detour
    November 28, 2018 - The Dangerous Detour Citation Text: Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
  19. psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
    June 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment Citation Text: Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …
  20. AHRQ PSNet Webinar (pdf file)

    psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
    January 01, 2025 - outcomes (2 RCTs, 1 NRCT) ► 2 RCTs with increased urine drug testing, opioid agreement documentation, guideline

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