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psnet.ahrq.gov/node/49467/psn-pdf
December 01, 2004 - A "Weak" Response
December 1, 2004
Reisman AB. A "Weak" Response. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/weak-response
The Case
A primary care physician on call for his group received a call at 9:00PM from a 68-year-old man. He said,
"They started me on a new pill for my blood pressure and now I fe…
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psnet.ahrq.gov/node/33850/psn-pdf
January 01, 2018 - EHR Copy and Paste and Patient Safety
January 1, 2018
Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
Perspective
Although the ability to copy and paste text is a central benefit of computing in general, and electronic…
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psnet.ahrq.gov/node/33815/psn-pdf
September 01, 2016 - Telemedicine and Patient Safety
September 1, 2016
Agboola SO, Kvedar JC. Telemedicine and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
Perspective
A paradigm shift is ongoing in the health care sector. The traditional model of episodic and hospital-base…
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psnet.ahrq.gov/node/49841/psn-pdf
September 01, 2018 - Chemotherapy Administration Safety Standards
September 1, 2018
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
The Case
A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…
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psnet.ahrq.gov/node/49505/psn-pdf
March 01, 2006 - Collegiality vs. Competence
March 1, 2006
Sagin T. Collegiality vs. Competence. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/collegiality-vs-competence
The Case
A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective
repair of a 10-cm abdominal aortic aneurys…
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psnet.ahrq.gov/node/33868/psn-pdf
October 01, 2018 - Safety in the Retail Pharmacy
October 1, 2018
Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-retail-pharmacy
Perspective
There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each
year.(1) Many patients interact w…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - PowerPoint Presentation
Spotlight Case
Multifactorial Medication Mishap
1
This presentation is based on the February 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Annie Yang, PharmD, BCPS
NYU Langone Medical Center
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/node/49477/psn-pdf
April 01, 2005 - Hold the tPA
April 1, 2005
Fagan SC. Hold the tPA. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hold-tpa
The Case
A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency
department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…
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psnet.ahrq.gov/node/49590/psn-pdf
January 01, 2010 - Is the Admission Drug Dose Too Low?
August 1, 2009
Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
The Case
A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to
the hospit…
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psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Check the Anesthesia Machine
December 1, 2013
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/check-anesthesia-machine
The Case
A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension,
diabetes, sleep apnea…
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psnet.ahrq.gov/node/72737/psn-pdf
February 09, 2021 - Geisinger’s Outpatient Addiction Medicine Specialty
Program Uses Data-Driven Decision Making and MAT to
Reduce Mortality Rates
February 9, 2021
https://psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-
driven-decision
Summary
The team at Geisinger sought to develop a…
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psnet.ahrq.gov/primer/opioid-safety
December 15, 2024 - Opioid Safety
Citation Text:
Opioid Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Ci…
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psnet.ahrq.gov/primer/health-care-associated-infections
December 15, 2024 - Healthcare-associated Infections
Citation Text:
Healthcare - Associated Infections. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/node/33565/psn-pdf
September 01, 2024 - Healthcare-associated Infections
June 15, 2024
Healthcare - Associated Infections. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/health-care-associated-infections
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice …
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 2024 - SPOTLIGHT CASE
Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head
Citation Text:
Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
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psnet.ahrq.gov/primer/maternal-safety
January 10, 2024 - Maternal Safety
Citation Text:
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
May 01, 2009 - prescription refills, communication to patients of lab results, reminders of preventive services, or guideline-based
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - The AAOS Clinical Practice Guideline Summary for the Management of Acute Compartment Syndrome provides
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psnet.ahrq.gov/web-mm/urine-tough-position
January 01, 2009 - Urine a Tough Position
Citation Text:
Gandhi TK. Urine a Tough Position. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…