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4801. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49612/psn-pdf
      November 01, 2010 - Treatment Challenges After Discharge November 1, 2010 Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge Case Objectives Understand types and frequencies of adverse events occurring between patient discharge from the hospital …

4802. Pathologic Mistake | PSNet
      psnet.ahrq.gov/web-mm/pathologic-mistake
      February 15, 2010 - Pathologic Mistake Citation Text: Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

4803. The Dropped "No" | PSNet
      psnet.ahrq.gov/web-mm/dropped-no
      October 30, 2019 - The Dropped "No" Citation Text: Johnson AJ. The Dropped "No". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

4804. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73650/psn-pdf
      August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax August 25, 2021 Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…

4805. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841469/psn-pdf
      December 14, 2022 - Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. December 14, 2022 Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-mi…

4806. Caution, Interrupted | PSNet
      psnet.ahrq.gov/web-mm/caution-interrupted
      October 01, 2016 - Caution, Interrupted Citation Text: Wears RL. Caution, Interrupted. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

4807. Inflicting Confusion | PSNet
      psnet.ahrq.gov/web-mm/inflicting-confusion
      August 04, 2021 - Inflicting Confusion Citation Text: Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

4808. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. | PSNet
      psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
      February 21, 2020 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. Citation Text: Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. …

4809. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72834/psn-pdf
      March 10, 2021 - Approach to Improving Patient Safety: Communication March 10, 2021 Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication Introduction Each one of the countless necessa…

4810. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49568/psn-pdf
      September 01, 2008 - Failure to Latch September 1, 2008 Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/failure-latch The Case The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to breastfeeding exclusively for 6 months. However, early br…

4811. Abdominal Aortic Aneurysm Screening | PSNet
      psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
      October 01, 2011 - SPOTLIGHT CASE Abdominal Aortic Aneurysm Screening Citation Text: Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX E…

4812. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49419/psn-pdf
      October 01, 2003 - The Other Side October 1, 2003 Vincent CA. The Other Side. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/other-side Case Objectives List the factors contributing to wrong site surgery. Understand the key components of the Universal Protocol for eliminating wrong site, wrong procedure, wrong person surger…

4813. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49630/psn-pdf
      July 01, 2011 - Watch the Warfarin! July 1, 2011 Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/watch-warfarin Case Objectives Understand best practices for safe discharge of patients on warfarin. Describe recent advances in anticoagulation monitoring for ambulatory patients. Discu…

4814. Reconciling Doses | PSNet
      psnet.ahrq.gov/web-mm/reconciling-doses
      August 14, 2017 - SPOTLIGHT CASE Reconciling Doses Citation Text: Federico F. Reconciling Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

4815. Departure From Central Line Ritual | PSNet
      psnet.ahrq.gov/web-mm/departure-central-line-ritual
      October 13, 2018 - Departure From Central Line Ritual Citation Text: Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndN…

4816. In Conversation With… Erik Hollnagel, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
      February 26, 2025 - In Conversation With… Erik Hollnagel, PhD June 1, 2019  Citation Text: In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Forma…

4817. CVC Removal: A Procedure Like Any Other | PSNet
      psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
      October 01, 2018 - CVC Removal: A Procedure Like Any Other Citation Text: Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…

4818. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49411/psn-pdf
      July 01, 2003 - Code Status Confusion July 1, 2003 Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/code-status-confusion Case Objectives Appreciate challenges of determining goals of care in hospitalized patients Understand patients’ common misconceptions about CPR List typical mist…

4819. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.176_slideshow.ppt
      May 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case May 2008 Diagnosing HIV: It Doesn’t Take a Brain Surgeon Source and Credits This presentation is based on the May 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Roger Chou, MD, Oregon Health &…

4820. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49677/psn-pdf
      February 01, 2013 - CVC Placement: Speak Now or Do Not Use the Line February 1, 2013 Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line The Case A 48-year-old woman with a history of hypertension, psychiatric illness, and a…