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psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
June 01, 2018 - Safety Considerations in Building a Point-of-Care Ultrasound Program
Chris Moore, MD | June 1, 2018
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Citation Text:
Moore C. Safety Considerations in Building a Point-of-Care Ultrasound Program. …
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psnet.ahrq.gov/node/73334/psn-pdf
August 01, 2024 - An Inadvertent Bolus of Norepinephrine.
May 26, 2021
Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counc…
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - SPOTLIGHT CASE
An Inadvertent Bolus of Norepinephrine.
Citation Text:
Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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F…
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psnet.ahrq.gov/web-mm/compare-and-contrast
July 16, 2019 - SPOTLIGHT CASE
Compare and Contrast
Citation Text:
Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Andrew P.J. …
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - Implementing a Fall Prevention Program
Frances Healey, RN, PhD | December 1, 2011
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Citation Text:
Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - SPOTLIGHT CASE
Crossing the Line
Citation Text:
Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
December 07, 2009 - SPOTLIGHT CASE
No News May Not Be Good News
Citation Text:
Moore CR. No News May Not Be Good News. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment
Citation Text:
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. 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/web-mm/mismanagement-delirium
February 13, 2014 - Mismanagement of Delirium
Citation Text:
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - SPOTLIGHT CASE
A Weighty Mistake
Citation Text:
Bokser SJ. A Weighty Mistake. 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/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
November 16, 2022 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.
Citation Text:
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.. PSNet [inter…
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking
January 26, 2022
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
Disclosure of Relevant Financial Relationships: As a provider ac…
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Patient Safety Events Involving Opioid
Dose Stacking
Source and Credits
• This presentation is based on the January 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: Hollie Porras, PharmD, BCPS and Cathy Lammers…
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psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
August 04, 2021 - Transitions in Adolescent Medicine
Citation Text:
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - SPOTLIGHT CASE
Medication Reconciliation: Whose Job Is It?
Citation Text:
Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Duplicate Therapies in Retail Pharmacy
March 15, 2023
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
The Cases
Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection f…
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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - SPOTLIGHT CASE
Order Interrupted by Text: Multitasking Mishap
Citation Text:
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - SPOTLIGHT CASE
Transfer Troubles
Citation Text:
Hains IM. Transfer Troubles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/72835/psn-pdf
March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy
March 10, 2021
In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family
Cente…