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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx
Spotlight
Challenging Case of Multiple Suicide Attempts in a
Complex Patient with Psychiatric Comorbidities
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…
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psnet.ahrq.gov/node/49606/psn-pdf
August 01, 2010 - Weighing In on Surgical Safety
August 1, 2010
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/weighing-surgical-safety
Case Objectives
Identify the comorbidites associated with obesity that place patients at higher risk for surgical
complications.
Un…
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psnet.ahrq.gov/web-mm/emergency-error
January 18, 2013 - SPOTLIGHT CASE
Emergency Error
Citation Text:
Symons NRA. Emergency Error. 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/node/842923/psn-pdf
February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric
Patient Complicating Cardiac Surgery and Bedside Chest
Closure.
February 1, 2023
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient
Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …
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psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - A Weighty Mistake
March 1, 2013
Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/weighty-mistake
Case Objectives
Understand factors associated with weight-based dosing medication errors in pediatric populations.
Describe how adoption of computerized provider order entry (CPOE) s…
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psnet.ahrq.gov/node/33754/psn-pdf
September 01, 2013 - In Conversation With… Sidney Dekker, MA, MSc, PhD
September 1, 2013
In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
Editor's note: Sidney Dekker is Professor and Director of the Safety Science Innovation Lab at Grif…
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psnet.ahrq.gov/primer/long-term-care-and-patient-safety
February 24, 2022 - Long-term Care and Patient Safety
Citation Text:
Bakerjian D. Long-term Care and Patient 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/continuing-education
February 26, 2025 - Continuing Education
What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - Annual Perspective
Impact of System Failures on Healthcare Workers
George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD
| March 21, 2023
View more articles from the same authors.
Citation Text:
Zangaro G, Van CM, Mossburg S. Imp…
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psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
January 31, 2024 - The Unhappy Patient Leaves Against Medical Advice.
Citation Text:
Nichols A. The Unhappy Patient Leaves Against Medical Advice.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Google Scholar …
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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Mismanagement of Delirium
May 1, 2016
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/mismanagement-delirium
The Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although
fitted with a cast at a regional ho…
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psnet.ahrq.gov/node/33723/psn-pdf
December 01, 2011 - Implementing a Fall Prevention Program
December 1, 2011
Healey F. Implementing a Fall Prevention Program. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/implementing-fall-prevention-program
Perspective
Throughout the developed world, most hospital beds are occupied by older people, many of whom have
b…
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psnet.ahrq.gov/web-mm/premature-extubation
May 25, 2011 - Premature Extubation
Citation Text:
Sagana R, Hyzy RC. Premature Extubation. 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/node/49437/psn-pdf
March 01, 2004 - Crossing the Line
March 1, 2004
Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/crossing-line
Case Objectives
Review complications of central venous catheterization
Discuss patient and operator factors that affect complication rates
Describe methods for preventing c…
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - No News May Not Be Good News
August 1, 2012
Moore CR. No News May Not Be Good News. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
Case Objectives
Describe the frequency with which ambulatory test results are not followed up by providers.
Appreciate that inadequate follow-up of…
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - Spinal Epidural Abscess
Citation Text:
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia
February 01, 2004 - Renal Failure Due to Benign Prostatic Hyperplasia
Citation Text:
Barry MJ, Garnick MB. Renal Failure Due to Benign Prostatic Hyperplasia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google…
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax
Citation Text:
Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …
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psnet.ahrq.gov/web-mm/its-sarah-not-stephen
January 01, 2015 - SPOTLIGHT CASE
It's Sarah, Not Stephen!
Citation Text:
Sarkar U. It's Sarah, Not Stephen!. 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/mechanical-prosthetic-valve-thrombosis-thromboembolism
August 21, 2005 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism.
Citation Text:
Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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…