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  1. psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
    October 30, 2019 - place with a really high or a really low C-Section rate, it tells you something about the other quality indicators
  2. psnet.ahrq.gov/web-mm/infused-not-ingested
    February 01, 2017 - Infused, Not Ingested Citation Text: Foley M. Infused, Not Ingested. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865984/psn-pdf
    May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. May 29, 2024 Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D- dimer. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49806/psn-pdf
    September 01, 2017 - Failed Interpretation of Screening Tool: Delayed Treatment September 1, 2017 Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment The Case An 88-year-old man present…
  5. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
    May 01, 2017 - PowerPoint Presentation Spotlight Diagnostic Delay in the Emergency Department 1 Source and Credits This presentation is based on the May 2017 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49451/psn-pdf
    June 01, 2004 - The Result Stopped Here June 1, 2004 Astion ML. The Result Stopped Here. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/result-stopped-here The Case A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital for continued wound care and intravenous (IV) antib…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857260/psn-pdf
    November 30, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! November 30, 2023 Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/when…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49440/psn-pdf
    March 01, 2004 - Autopsy Revelation March 1, 2004 Shojania KG. Autopsy Revelation. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/autopsy-revelation The Case A 45-year-old male with development delay presented to the emergency department with acute abdominal pain. His mother, who was his main caregiver, accompanied him. Th…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49446/psn-pdf
    August 30, 2021 - Too Tight Control May 1, 2004 Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/too-tight-control Case Objectives Appreciate the advantages and potential complications of intensive insulin therapy in the hospitalized patient List hospital-based safeguards available to…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33864/psn-pdf
    January 01, 2019 - How Does Health Care Simulation Affect Patient Care? August 1, 2018 Lopreiato JO. How Does Health Care Simulation Affect Patient Care? PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care Perspective Introduction Health care simulation programs have spread…
  11. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.176_slideshow.ppt
    May 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case May 2008 Diagnosing HIV: It Doesn’t Take a Brain Surgeon Source and Credits This presentation is based on the May 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Roger Chou, MD, Oregon Health &…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49544/psn-pdf
    September 01, 2007 - Discharging Our Responsibility September 1, 2007 Fonarow GC. Discharging Our Responsibility. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/discharging-our-responsibility The Case A 75-year-old man with a history of hypertension, coronary artery disease, and congestive heart failure (CHF) presented to the …
  13. psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
    November 08, 2013 - Diffusion of Responsibility Leads to Danger Citation Text: Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar…
  14. psnet.ahrq.gov/web-mm/wrong-channel
    February 01, 2003 - The Wrong Channel Citation Text: Gosbee JW. The Wrong Channel . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
  15. psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
    September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization Citation Text: Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49582/psn-pdf
    April 01, 2009 - Breakage of a PICC Line April 1, 2009 Dimov V. Breakage of a PICC Line. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/breakage-picc-line Case Objectives Appreciate the incidence and consequences of PICC line breakage. Understand the risk factors for PICC line breakage. Understand the treatment options in…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33743/psn-pdf
    December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit December 1, 2012 Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit. PSNet [internet]. 2012. https://psnet.ahrq.gov…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49545/psn-pdf
    September 01, 2007 - Coming Undone: Failure of Closure Device September 1, 2007 Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device The Case A 65-year-old man underwent coronary angiography because of atypical exertional chest…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49594/psn-pdf
    December 01, 2009 - Standard Deviations December 1, 2009 Sabin JE. Standard Deviations. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/standard-deviations Case Objectives Understand the safety risks associated with patients being discharged against medical advice (AMA). Recognize safety risks associated with being part of a …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846770/psn-pdf
    March 29, 2023 - Procedure Complications – Who is Responsible for Follow up? March 29, 2023 Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up? PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow The Case A 74-year-old man with newly diagnose…

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