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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - Infused, Not Ingested
November 1, 2005
Foley M. Infused, Not Ingested. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/infused-not-ingested
The Case
A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering
contrast, an unfamiliar task for this particular nurse. Rathe…
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - Inadvertent Castration
Citation Text:
Calland FJ. Inadvertent Castration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…
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psnet.ahrq.gov/web-mm/carpe-diem-seize-day
September 01, 2012 - Carpe Diem (Seize the Day)
Citation Text:
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
January 01, 2022 - Spotlight
Spotlight
Strongyloides: A Hidden Traveler
and Potentially Lethal Missed
Diagnosis
Source and Credits
• This presentation is based on the November 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: Narath Carlile MD MPH,…
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psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - Check the Anesthesia Machine
Citation Text:
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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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:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/web-mm/feeling-no-pain
August 30, 2023 - Feeling No Pain
Citation Text:
Bogner MS. Feeling No Pain. 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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…
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psnet.ahrq.gov/node/49444/psn-pdf
May 01, 2004 - Do Me a Favor
May 1, 2004
Williamson A. Do Me a Favor. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/do-me-favor
The Case
A 26-year-old gravida 4 para 1 woman reported that her last menstrual period was 5 weeks prior, and she
had a positive home pregnancy test. With a history of one ectopic pregnancy, one…
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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/49703/psn-pdf
March 01, 2014 - After-Visit Confusion
March 1, 2014
Ventres W. After-Visit Confusion. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/after-visit-confusion
The Case
An otherwise healthy 18-year-old woman presented to an urgent care clinic with new bumps and white
spots near her tongue. The patient's mother accompanied her …
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psnet.ahrq.gov/web-mm/nonsustained-ventricular-tachycardia-after-acute-coronary-syndromes-recognizing-high-risk
September 20, 2011 - Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients
Citation Text:
Piccini JP, Newby KL, Califf R. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
February 01, 2010 - sure that there is oversight of the patient care transitions, which currently does not necessarily happen … I am very hopeful that two other things will happen.
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psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
February 01, 2010 - sure that there is oversight of the patient care transitions, which currently does not necessarily happen … I am very hopeful that two other things will happen.
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psnet.ahrq.gov/node/33809/psn-pdf
June 01, 2016 - When I think
back to my days at AHRQ, we had a fantasy that something like this would begin to happen
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - How then did it happen, and what are the implications for the use of checklists and order sets in medicine
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psnet.ahrq.gov/node/33805/psn-pdf
April 01, 2016 - to come together because of the other pressures in
the environment, or CLER is actually making that happen
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psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - Performing an invasive procedure on the wrong patient should never happen.
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - They need to be aware of what may happen and when to reach out to their physician or go to the emergency
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psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
February 26, 2025 - on these high beds with a step stool beside it and that actually becomes like an accident waiting to happen
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psnet.ahrq.gov/node/837958/psn-pdf
December 01, 2021 - EMS Perils from Hospital Overcrowding
August 31, 2022
Brown S, Rose JS, Barnes DK. EMS Perils from Hospital Overcrowding. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
The Case
A 71-year-old man with a history of postoperative septic knee arthritis (status: post-intravenous…