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  1. psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
    May 01, 2008 - SPOTLIGHT CASE A Painful Medication Reconciliation Mishap Citation Text: Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google S…
  2. psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
    August 20, 2018 - A Double “Never Event”: Wrong Patient and Wrong Side. Citation Text: Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842919/psn-pdf
    February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis. February 1, 2023 Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis The Cases Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
  4. psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
    February 01, 2023 - SPOTLIGHT CASE When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Citation Text: Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49579/psn-pdf
    March 21, 2009 - All in the History March 21, 2009 Fee C. All in the History. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/all-history Case Objectives Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it does not apply to transfers to emergency departments from non-acute care faci…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49744/psn-pdf
    October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy October 1, 2015 Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33785/psn-pdf
    May 01, 2015 - In Conversation With… John D. Birkmeyer, MD May 1, 2015 In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md Editor's note: John D. Birkmeyer, MD, is an internationally recognized health services researcher with expertise in perfo…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49675/psn-pdf
    February 01, 2013 - Delay in Treatment: Failure to Contact Patient Leads to Significant Complications February 1, 2013 Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complicat…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49777/psn-pdf
    December 01, 2016 - Suicidal Ideation in the Family Medicine Clinic December 1, 2016 Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic Case Objectives Recognize suicide as a major public health problem and the critical role of pri…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33879/psn-pdf
    May 01, 2019 - In Conversation With… Jane Brice, MD, MPH May 1, 2019 In Conversation With… Jane Brice, MD, MPH. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph Editor's note: Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49825/psn-pdf
    April 01, 2018 - When Patients and Providers Speak Different Languages April 1, 2018 Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages Case Objectives Understand the legal and regulatory obligations to prov…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49486/psn-pdf
    August 21, 2005 - Impatient Inpatient Dosing August 21, 2005 White RH. Impatient Inpatient Dosing. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/impatient-inpatient-dosing Case Objectives Appreciate the challenges of initiating warfarin therapy in the hospitalized patient Understand the fundamental pharmacology of warfarin…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49585/psn-pdf
    May 01, 2009 - Delirium or Dementia? May 1, 2009 Rudolph JL. Delirium or Dementia? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/delirium-or-dementia Case Objectives State the key diagnostic differences between delirium and dementia. Describe the Confusion Assessment Method for workup of suspected delirium. Explain the…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49478/psn-pdf
    April 01, 2005 - Compare and Contrast April 1, 2005 Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/compare-and-contrast Case Objectives Define contrast nephropathy (CN) List risk factors for CN Implement pharmacologic strategies for CN prophylaxis Follow an algorithm for CN risk …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61082/psn-pdf
    July 23, 2020 - Long-Term Care and the Response to COVID-19 October 28, 2020 Popejoy LL, Crecelius CA, Fitall E, et al. Long-Term Care and the Response to COVID-19. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/long-term-care-and-response-covid-19 The COVID-19 pandemic has had far-reaching consequences on how the hea…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863308/psn-pdf
    February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy February 28, 2024 Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy The Case A…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73200/psn-pdf
    April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions April 28, 2021 Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions The Case  A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and severe e…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49624/psn-pdf
    May 01, 2011 - Duty to Disclose Someone Else's Error? May 1, 2011 Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error Case Objectives State the rationale for disclosing medical errors. Describe key principles in effective error disclosure. …
  19. psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx Spotlight Respiratory Distress after Neck Surgery: Two Cases of Post-Operative Cervical Hematoma Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49758/psn-pdf
    April 01, 2016 - Dropping to New Lows April 1, 2016 Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/dropping-new-lows Case Objectives State how to manage diabetes medications when patients are admitted to the hospital Describe a guideline-recommended insulin regimen for a hospitaliz…

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