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psnet.ahrq.gov/node/49794/psn-pdf
May 01, 2017 - Communication Error in a Closed ICU
May 1, 2017
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/communication-error-closed-icu
The Case
A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney
transplant), co…
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psnet.ahrq.gov/node/33820/psn-pdf
December 01, 2016 - In Conversation With... James P. Bagian, MD, PE
December 1, 2016
In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
Editor's note: Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the
Uni…
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psnet.ahrq.gov/node/73998/psn-pdf
October 27, 2021 - The Hidden Danger of Unseen Intravenous Catheters
October 27, 2021
Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
The Case
A 6-week-old infant underwent a craniotomy and excision of abnormal bra…
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psnet.ahrq.gov/node/49706/psn-pdf
January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication
Access Issue
April 1, 2014
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
The Case
A 24-year-old wom…
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psnet.ahrq.gov/node/838972/psn-pdf
October 27, 2022 - The Unhappy Patient Leaves Against Medical Advice.
October 27, 2022
Nichols A. The Unhappy Patient Leaves Against Medical Advice. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
The Case
A 61-year-old woman was placed on bedrest following major surgery. Her posto…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
August 01, 2014 - PowerPoint Presentation
Spotlight
Pitfalls in Diagnosing Necrotizing Fasciitis
This presentation is based on the July/August 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Terence Goh, MBBS, Department of Plastic Surgery, Singapore General Hos…
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psnet.ahrq.gov/node/49696/psn-pdf
December 01, 2013 - New Oral Anticoagulants
December 1, 2013
Fang MC. New Oral Anticoagulants. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/new-oral-anticoagulants
Case Objectives
Review properties of newer target-specific oral anticoagulants (TSOACs) such as dabigatran,
rivaroxaban, and apixaban.
State key perioperative c…
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psnet.ahrq.gov/node/840175/psn-pdf
November 16, 2022 - Mechanical Prosthetic Valve Thrombosis with
Thromboembolism.
November 16, 2022
Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
The Case
A 61-year-old woman presented to …
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psnet.ahrq.gov/node/33691/psn-pdf
December 01, 2009 - How to Identify and Manage Problem Behaviors
December 1, 2009
Rosenstein AH, O'Daniel M. How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
Perspective
The 1999 Institute of Medicine report highlighted the need for heal…
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psnet.ahrq.gov/node/49554/psn-pdf
January 01, 2008 - Chemotherapy Extravasation
January 1, 2008
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/chemotherapy-extravasation
The Case
A 73-year-old woman with no past medical history was diagnosed with stage IIIA breast cancer. She and
her oncologist decided to begin sys…
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psnet.ahrq.gov/node/49662/psn-pdf
August 01, 2012 - Wrong Turn through Colon: Misplaced PEG
August 1, 2012
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
The Case
An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…
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psnet.ahrq.gov/web-mm/one-dose-fifty-pills
January 13, 2021 - One Dose, Fifty Pills
Citation Text:
Smith L. One Dose, Fifty Pills
. 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 Endnote tagged PubMe…
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psnet.ahrq.gov/node/836939/psn-pdf
April 27, 2022 - A Virtual Hospitalist Program to Address a Hospital’s
Challenges at the Start of the COVID-19 Pandemic
April 27, 2022
https://psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-
pandemic
Summary
In the early days of the COVID-19 pandemic, New York Presbyterian Weill …
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psnet.ahrq.gov/node/33642/psn-pdf
November 01, 2006 - In Conversation With...Donald A. Norman, PhD
November 1, 2006
In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you
become interested…
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psnet.ahrq.gov/node/49462/psn-pdf
October 01, 2004 - Thin Air
October 1, 2004
Gaba DM. Thin Air. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/thin-air
Case Objectives
Identify the gas-specific non-interchangeable connectors used for bulk gas supply outlets in
hospitals.
Define forcing function, both in engineered safety devices and in human procedures.
R…
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psnet.ahrq.gov/node/33722/psn-pdf
December 01, 2011 - In Conversation With… Ann L. Hendrich, RN, PhD
December 1, 2011
In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
Editor's note: Ann L. Hendrich, RN, PhD, is Vice President of Clinical Excellence Operations and
Executive Di…
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psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
August 31, 2020 - Annual Perspective
Approach to Improving Patient Safety: Communication
March 10, 2021
View more articles from the same authors.
Citation Text:
Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. Ro…
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psnet.ahrq.gov/node/33697/psn-pdf
June 01, 2010 - What Do We Know About Emergency Department Safety?
June 1, 2010
Sklar DP, Crandall CS. What Do We Know About Emergency Department Safety? PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
Perspective
Emergency medicine has evolved from a location, with var…
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psnet.ahrq.gov/web-mm/triage-time-bomb
September 01, 2008 - Triage Time Bomb
Citation Text:
Washington DL. Triage Time Bomb. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/say-it-again
January 31, 2020 - Say It Again
Citation Text:
Henriksen K, Hall KK. Say It Again. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
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…