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  1. psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
    December 23, 2020 - SPOTLIGHT CASE Recurrent Hypoglycemia: A Care Transition Failure? Citation Text: Eytan T. Recurrent Hypoglycemia: A Care Transition Failure?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format:…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33803/psn-pdf
    January 01, 2015 - In Conversation With… Richard Kronick, PhD February 1, 2014 In Conversation With… Richard Kronick, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-richard-kronick-phd Editor's note: Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since August 2013 …
  3. psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
    September 15, 2024 - Retained Surgical Items: Definition and Epidemiology. Citation Text: Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …
  4. psnet.ahrq.gov/perspective/communication-during-transitions-care
    July 10, 2024 - Annual Perspective Communication During Transitions of Care Ayse P. Gurses; Sarah Mossburg; Zoe Sousane | March 27, 2024  View more articles from the same authors. Citation Text: Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PS…
  5. psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
    August 25, 2021 - SPOTLIGHT CASE Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. Citation Text: Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
  6. psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
    September 27, 2023 - Verbal Orders and Medication Overrides: A Dangerous Combination Citation Text: Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
  7. psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
    September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures Citation Text: Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: …
  8. psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
    April 01, 2008 - SPOTLIGHT CASE A "Reflexive" Diagnosis in Primary Care Citation Text: Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: …
  9. psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
    February 01, 2023 - SPOTLIGHT CASE Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump Citation Text: Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump . PSNet [internet]. Rockville (MD): Agency for Heal…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848108/psn-pdf
    April 26, 2023 - example, potassium supplements for a patient on furosemide is routine, however, this same drug may lead
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60241/psn-pdf
    February 24, 2022 - Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes February 24, 2022 Bakerjian D. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-…
  12. psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
    October 01, 2007 - SPOTLIGHT CASE Suicidal Ideation in the Family Medicine Clinic Citation Text: Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: …
  13. psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
    November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions Citation Text: Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…
  14. psnet.ahrq.gov/web-mm/delirium-or-dementia
    September 27, 2023 - SPOTLIGHT CASE Delirium or Dementia? Citation Text: Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49831/psn-pdf
    June 01, 2018 - Chest Pain in a Rural Hospital June 1, 2018 MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital Case Objectives Recognize that a significant proportion of the Unites States population receives care in rural safety net emergency dep…
  16. psnet.ahrq.gov/web-mm/forgotten-turn
    August 01, 2018 - SPOTLIGHT CASE The Forgotten Turn Citation Text: Barbour S. The Forgotten Turn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
  17. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50698/psn-pdf
    November 27, 2019 - Missed Opportunities for Suicide Risk Assessment November 27, 2019 Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…
  19. psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
    September 01, 2016 - SPOTLIGHT CASE Multifactorial Medication Mishap Citation Text: Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNot…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50841/psn-pdf
    January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near- Miss Wrong Transfusion Event January 29, 2020 Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…

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