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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…
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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…
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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…
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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.
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Format:
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…
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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.
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Format:
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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…
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psnet.ahrq.gov/web-mm/amphotericin-toxicity
April 01, 2014 - Amphotericin Toxicity
Citation Text:
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
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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…
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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…
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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…
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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…
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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…
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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…
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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.
…
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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…
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psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - This recommendation was likely carefully worded because the guideline writers knew that is what hospitals
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psnet.ahrq.gov/node/49597/psn-pdf
February 01, 2010 - Adolescent Diabetes: A Routine Visit?
February 1, 2010
Slap GB. Adolescent Diabetes: A Routine Visit? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
Case Objectives
Appreciate the increasing prevalence of obesity and type 2 diabetes mellitus (T2DM) among
adolescents in the…
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psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room.
Citation Text:
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - SPOTLIGHT CASE
Spotlight: Mistaken Attribution, Diagnostic Misstep
Citation Text:
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…