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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - Spotlight
Missed Opportunities for Suicide
Risk Assessment
Source and Credits
• This presentation is based on the November 2019 AHRQ WebM&M
Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Glen Xiong, MD & Debra Kahn, MD
○ Editors in Chief, AHRQ We…
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a
Patient Admitted for Leg Fractures
March 27, 2024
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
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psnet.ahrq.gov/node/33807/psn-pdf
May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD
May 1, 2016
In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
Editor's note: Dr. Drew, a nurse researcher, is the David Mortara Distinguished Professor of Physiological
Nursing and…
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psnet.ahrq.gov/node/49798/psn-pdf
July 01, 2017 - Pseudo-obstruction But a Real Perforation
July 1, 2017
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
Case Objectives
Recognize acute colonic pseudo-obstruction and implement a medical management plan.
Ide…
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psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
June 24, 2010 - Methicillin-Resistant Staphylococcus aureus
Gary A. Noskin, MD | April 1, 2008
View more articles from the same authors.
Citation Text:
Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…
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psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
September 22, 2010 - Inappropriate Antibiotic Use
Citation Text:
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. 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 …
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psnet.ahrq.gov/node/49600/psn-pdf
April 01, 2010 - Bad Writing, Wrong Medication
April 1, 2010
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
Case Objectives
Differentiate between a medication error and an adverse drug event.
Appreciate the system complexities involved in medication erro…
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - SPOTLIGHT CASE
Double Trouble
Citation Text:
Gurwitz JH. Double Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/node/49402/psn-pdf
June 01, 2003 - Inappropriate Antibiotic Use
June 1, 2003
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
The Case
A 41-year-old woman presented to the hospital with acute renal failure, which came to be diagnosed as a
first presentation of s…
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - SPOTLIGHT CASE
Transfusion Thresholds in Gastrointestinal Bleeding
Citation Text:
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
January 01, 2024 - The Different Count Contributions to Retention
Differential Count Contributions in Retained Surgical Sponge Cases: Examination of Administrative Penalty
Cases from the California Department of Public Health (CDPH), Health and Safety Code Section 1280.1
Enforcement Reports from 2007-2014
A NoThing Left Behin…
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psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
September 29, 2021 - Compartment syndrome is a clinical diagnosis and patients’ reported symptoms are the earliest indicators
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psnet.ahrq.gov/issue/post-hospital-medication-discrepancies-home-risk-factor-90-day-return-emergency-department
March 18, 2020 - Study
Post-hospital medication discrepancies at home: risk factor for 90-day return to emergency department.
Citation Text:
Costa LL, Byon HD. Post-Hospital Medication Discrepancies at Home: Risk Factor for 90-Day Return to Emergency Department. J Nurs Care Qual. 2018;33(2):180-186. doi:…
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psnet.ahrq.gov/issue/no-shortcuts-safer-opioid-prescribing
March 30, 2016 - Commentary
Classic
No shortcuts to safer opioid prescribing.
Citation Text:
Dowell D, Haegerich T, Chou R. No Shortcuts to Safer Opioid Prescribing. N Engl J Med. 2019;380(24):2285-2287. doi:10.1056/NEJMp1904190.
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psnet.ahrq.gov/issue/trend-analysis-radiation-therapy-incidents-over-seven-years
December 20, 2023 - Study
Trend analysis of radiation therapy incidents over seven years.
Citation Text:
Bissonnette J-P, Medlam G. Trend analysis of radiation therapy incidents over seven years. Radiother Oncol. 2010;96(1):139-44. doi:10.1016/j.radonc.2010.05.002.
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DOI …
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psnet.ahrq.gov/issue/what-about-doctors-impact-medical-errors
January 14, 2015 - Commentary
What about doctors? The impact of medical errors.
Citation Text:
Elwahab SA, Doherty E. What about doctors? The impact of medical errors. Surgeon. 2014;12(6):297-300. doi:10.1016/j.surge.2014.06.004.
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DOI Google Scholar PubMed BibTeX EndNote …
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psnet.ahrq.gov/issue/infection-control-hazards-and-near-misses-reported-nursing-students
February 11, 2009 - Study
Infection control hazards and near misses reported by nursing students.
Citation Text:
Geller NF, Bakken S, Currie LM, et al. Infection control hazards and near misses reported by nursing students. Am J Infect Control. 2010;38(10):811-6. doi:10.1016/j.ajic.2010.06.001.
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psnet.ahrq.gov/issue/potential-drug-interactions-hospitalized-cancer-patients
June 07, 2016 - Study
Potential for drug interactions in hospitalized cancer patients.
Citation Text:
Riechelmann RP, Moreira F, Smaletz Ò, et al. Potential for drug interactions in hospitalized cancer patients. Cancer Chemother Pharmacol. 2005;56(3). doi:10.1007/s00280-004-0998-4.
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…
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psnet.ahrq.gov/issue/can-electronic-clinical-documentation-help-prevent-diagnostic-errors
December 02, 2020 - Commentary
Can electronic clinical documentation help prevent diagnostic errors?
Citation Text:
Schiff G, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? New Engl J Med. 2010;362(12):1066-1069. doi:10.1056/NEJMp0911734.
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