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psnet.ahrq.gov/node/49553/psn-pdf
January 01, 2008 - contaminated-or-not-guidelines-interpretation-positive-blood-cultures
The Case
A 62-year-old man with type 2 diabetes mellitus, chronic kidney … disease, and a history of ventricular
tachycardia with an automated implantable cardiac defibrillator
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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a
Patient Admitted for Leg Fractures
March 27, 2024
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - Lost in Sign Out and Documentation
April 1, 2016
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
The Case
A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the
emergency physician, …
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - coronary
artery disease, congestive heart failure with an ejection fraction of 45%, stage I chronic kidney … disease and
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
A 69-year-old man with a history of cervical stenosis, coronary artery disease, chronic kidney … disease, and
hypertension developed worsening neck pain in the previous year, which prevented him from
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - The Case
A 69-year-old man with a history of cervical stenosis, coronary artery disease, chronic kidney … disease, and hypertension developed worsening neck pain in the previous year, which prevented him from
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psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
January 01, 2024 - baseline renal function and any previous episodes of hyperkalemia, as chronic hyper-kalemia with chronic kidney … disease may not require prompt treatment.6
The combination of hyponatremia and hyperkalemia is explained
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psnet.ahrq.gov/node/865466/psn-pdf
March 27, 2024 - Equity in Patient Safety
March 27, 2024
Thomas A, Lee M, Mossburg S. Equity in Patient Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/equity-patient-safety
Introduction
Safety and equity are among the central components that determine quality of care, according to nonprofit
advisory agencies l…
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psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something
May 01, 2019 - Liver Failure After Chemotherapy: Did We Forget Something?
Citation Text:
Lubel J. Liver Failure After Chemotherapy: Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
G…
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
Citation Text:
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
December 01, 2017 - As an example, in patients with congestive heart failure and chronic kidney disease taking diuretic therapy
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psnet.ahrq.gov/node/49843/psn-pdf
October 01, 2018 - Spotlight: Overdiagnosis and Delay: Challenges in Sepsis
Diagnosis
October 1, 2018
Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
Case Objectives
Realize the im…
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psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
January 01, 2015 - Annual Perspective
Patient Safety and Opioid Medications
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2016
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. Ro…
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psnet.ahrq.gov/node/49755/psn-pdf
February 01, 2016 - Good Night's Sleep Gone Wrong
February 1, 2016
Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
The Case
A 64-year-old woman came to the emergency department complaining of cough and shortness of breath,
along with an…
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - The patient had a past medical history of morbid obesity, hypertension, heart failure, chronic kidney … disease (stage 3), diabetes, peripheral artery disease, and ischemic cardiomyopathy.
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psnet.ahrq.gov/perspective/equity-patient-safety
September 24, 2024 - Annual Perspective
Equity in Patient Safety
Angela D. Thomas, DrPH, MPH, MBA; Merton Lee, PhD, PharmD; Sarah Mossburg, RN, PhD
| March 27, 2024
View more articles from the same authors.
Citation Text:
Thomas A, Lee M, Mossburg S. Equity in Patient Safety. …
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - twice daily). 12,13 A meta-analysis has shown that use of apixaban in patients with stage 4 chronic kidney … disease appears to be associated with: no difference in the incidence of major bleeding compared to
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Spotlight
Spotlight
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
1
Source and Credits
This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Samantha Brown…
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psnet.ahrq.gov/node/49721/psn-pdf
December 01, 2014 - Ebola: Are We Ready?
December 1, 2014
Barsuk JH, Barnard C. Ebola: Are We Ready? PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/ebola-are-we-ready
The Case
A 28-year-old man, well-appearing but pale, walked into the emergency department (ED) on a Wednesday
afternoon at 3 PM complaining of nausea, vomiting,…
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psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - November 28, 2012
Chronic kidney disease adversely influences patient safety.