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psnet.ahrq.gov/web-mm/check-wristband
August 03, 2009 - Check the Wristband
Citation Text:
Rosenthal M. Check the Wristband. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
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: Elizabeth Gould, NP-C, COR…
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psnet.ahrq.gov/web-mm/perils-contrast-media
March 01, 2007 - SPOTLIGHT CASE
The Perils of Contrast Media
Citation Text:
Sadat U, Solomon R. The Perils of Contrast Media. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Google Scholar BibTeX En…
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psnet.ahrq.gov/node/72563/psn-pdf
December 07, 2020 - In Conversation With... Katie J. Suda, PharmD, MS
December 7, 2020
In Conversation With.. Katie J. Suda, PharmD, MS . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
Editor’s Note: Katie J. Suda, PharmD, MS is a professor at the University of Pittsburgh School of Medic…
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psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
January 29, 2020 - Delayed Recognition of a Positive Blood Culture
Citation Text:
Doernberg S. Delayed Recognition of a Positive Blood Culture. 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/node/857259/psn-pdf
November 30, 2023 - Medication Mix-Up Leads to Patient Death
November 30, 2023
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
The Case
An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
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psnet.ahrq.gov/node/33877/psn-pdf
April 01, 2019 - In Conversation With… Timothy B. McDonald, MD, JD
April 1, 2019
In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
Editor's note: Dr. McDonald is President of the Center for Open and Honest Communication at the
MedStar…
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psnet.ahrq.gov/node/855057/psn-pdf
October 31, 2023 - Addressing Workplace Violence and Creating a Safer
Workplace
October 31, 2023
Jones CB, Sousane Z, Mossburg S. Addressing Workplace Violence and Creating a Safer Workplace.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
While violence in the w…
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psnet.ahrq.gov/node/49669/psn-pdf
November 01, 2012 - Transfusion Overload
November 1, 2012
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfusion-overload
Case Objectives
Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit
below 30% are not supported by the evidence.…
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psnet.ahrq.gov/node/33738/psn-pdf
December 01, 2012 - In Conversation With... John G. Reiling, PhD
December 1, 2012
In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
Editor's note: John G. Reiling, PhD, is president and CEO of Safe by Design. Dr. Reiling consults with
hospitals and…
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psnet.ahrq.gov/node/49516/psn-pdf
August 01, 2006 - Physical Diagnosis: A Lost Art?
August 1, 2006
Thompson GR, Verghese A. Physical Diagnosis: A Lost Art? PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
Case Objectives
Appreciate the decline in proficiency and reliance on physical examination skills among health care
providers.
…
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psnet.ahrq.gov/node/49663/psn-pdf
September 01, 2012 - Peripheral IV in Too Long
September 1, 2012
Fang C-T. Peripheral IV in Too Long. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/peripheral-iv-too-long
Case Objectives
Appreciate the complications associated with peripheral intravenous (IV) catheters.
Describe the optimal sterile technique that should be us…
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psnet.ahrq.gov/node/33801/psn-pdf
February 01, 2016 - In Conversation With…Christine A. Sinsky, MD
February 1, 2016
In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
Editor's note: Christine A. Sinsky, MD, is the Vice President for Professional Satisfaction at the American
Me…
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psnet.ahrq.gov/node/33822/psn-pdf
January 01, 2017 - In Conversation With… Paul H. O'Neill, MPA
January 1, 2017
In Conversation With… Paul H. O'Neill, MPA. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
Editor's note: Mr. O'Neill served as the United States Secretary of the Treasury under President George
W. Bush and, prio…
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psnet.ahrq.gov/node/49498/psn-pdf
January 01, 2006 - An Ounce of Prevention
January 1, 2006
Kucher N. An Ounce of Prevention. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/ounce-prevention
Case Objectives
Assess risk for venous thromboembolism (VTE) in hospitalized patients
List recommended strategies for VTE prevention for various risk groups
Identify pat…
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psnet.ahrq.gov/web-mm/ounce-prevention
February 17, 2011 - SPOTLIGHT CASE
An Ounce of Prevention
Citation Text:
Kucher N. An Ounce of Prevention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/49633/psn-pdf
September 01, 2011 - The Safety and Quality of Long Term Care
September 1, 2011
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
Case Objectives
Identify commonly reported adverse events in long-term care.
Identify two to three challenges…
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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - Check the Wristband
July 1, 2003
Rosenthal M. Check the Wristband. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/check-wristband
The Case
The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the
impending surgery. The patient spoke English and appeared to be of aver…
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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/node/60857/psn-pdf
August 26, 2020 - Nothing Called Small Surgery
August 26, 2020
Manske C. Nothing Called Small Surgery. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/nothing-called-small-surgery
The Case
A 56-year-old female presented to surgical clinic with pain and swelling in left great toe associated with
progressive deformity of the …