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psnet.ahrq.gov/node/49570/psn-pdf
October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure?
October 1, 2008
Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
Case Objectives
Understand the complementary abilities of an electronic health record a…
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psnet.ahrq.gov/node/49816/psn-pdf
January 01, 2018 - A Painful Medication Reconciliation Mishap
January 1, 2018
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
Case Objectives
Recognize that substance use disorders are common in patients with acute pain.
Understand th…
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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - Delayed Diagnosis and Treatment of an Occult
Hemothorax Following Complicated Central Line Insertion
Leads to Cardiac Arrest
January 26, 2022
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated
Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022.
https…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/node/33718/psn-pdf
October 01, 2011 - In Conversation With… Paul G. Shekelle, MD, MPH, PhD
October 1, 2011
In Conversation With… Paul G. Shekelle, MD, MPH, PhD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd
Editor's note: Dr. Shekelle is director of the Southern California Evidence-Based Practice Cen…
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psnet.ahrq.gov/node/49508/psn-pdf
January 01, 2007 - Language Barrier
April 1, 2006
Flores G. Language Barrier. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/language-barrier
The Case
A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish-
speaking parents when they noted that their daughter had generalized we…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - PowerPoint Presentation
Spotlight
A Lot of Pain (Medications)
1
This presentation is based on the September 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…
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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/node/49485/psn-pdf
August 29, 2024 - Blind Spot
June 1, 2005
Lee LA. Blind Spot. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/blind-spot
The Case
A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral
position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
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psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - Deaths Not Foretold: Are Unexpected Deaths Useful
Patient Safety Signals?
December 1, 2007
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
The Case
…
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psnet.ahrq.gov/node/33818/psn-pdf
November 01, 2016 - In Conversation With… Andrew Bindman, MD
November 1, 2016
In Conversation With… Andrew Bindman, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
Editor's note: Dr. Bindman was appointed as Director of the Agency for Healthcare Research and Quality
(AHRQ) in May 2016. P…
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psnet.ahrq.gov/node/49672/psn-pdf
January 01, 2013 - The Lung Nodule That Refused To Grow
December 1, 2012
Balekian AA, Gould MK. The Lung Nodule That Refused To Grow. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/lung-nodule-refused-grow
Case Objectives
Define a solitary pulmonary nodule.
Identify the different initial first steps of management.
Identify …
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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/node/33774/psn-pdf
December 01, 2014 - In Conversation With… Edward Kelley, PhD
December 1, 2014
In Conversation With… Edward Kelley, PhD. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
Editor's note: Edward Kelley, PhD, is Director of Service Delivery and Safety for the World Health
Organization (WHO). He ha…
-
psnet.ahrq.gov/node/49567/psn-pdf
September 01, 2008 - Empiric Steroids: the Good, the Bad, and the Ugly
September 1, 2008
Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
Case Objectives
Describe appropriate indications for use of steroids.
Appreciate contraindicati…
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psnet.ahrq.gov/web-mm/july-syndrome
July 01, 2011 - July Syndrome
Citation Text:
Young JQ. July Syndrome. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
D…
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psnet.ahrq.gov/node/49549/psn-pdf
December 06, 2007 - Elopement
December 1, 2007
Gerardi D. Elopement. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/elopement
Case Objectives
Define elopement and differentiate it from wandering and leaving against medical advice.
Identify leading contributors to elopement events.
Describe strategies for preventing elopement…
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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.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - Communication Failure—Who's in Charge?
Citation Text:
Fackler J, Schwartz JM. Communication Failure—Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTeX EndN…
-
psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - From Pain Relief to Risk: A Case of Suspected Opioid
Overdose in a Pediatric Patient
February 26, 2025
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a
Pediatric Patient. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overd…