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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/web-mm/milliliters-vs-milligrams
September 01, 2004 - Milliliters vs. Milligrams
Citation Text:
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/web-mm/allergy-holter
May 01, 2008 - Allergy to Holter
Citation Text:
Williams M. Allergy to Holter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
September 01, 2016 - PowerPoint Presentation
Spotlight
A Pill Organizing Plight
*
Source and Credits
This presentation is based on the September 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Ro…
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psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
October 01, 2013 - New Patient Mistakenly Checked in as Another
Citation Text:
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar B…
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psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
April 24, 2024 - Right Electrocardiogram, Wrong Patient
Citation Text:
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Format:
Google Scholar BibTeX EndNote…
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psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
January 01, 2019 - Spotlight
Spotlight
"Do You Want Everything Done?":
Clarifying Code Status
Source and Credits
• This presentation is based on the December 2019
AHRQ WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Karl Steinberg MD, CMD, HMDC & Thaddeus
M…
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psnet.ahrq.gov/node/33712/psn-pdf
June 01, 2011 - In Conversation with… Edward Tenner, PhD
June 1, 2011
In Conversation with… Edward Tenner, PhD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
Editor's note: Edward Tenner is an independent writer, speaker, and consultant on technology and
culture. He received his PhD fro…
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psnet.ahrq.gov/node/49432/psn-pdf
February 09, 2004 - Delay in Initiating Antibiotics Results in Fatal Error
February 1, 2004
Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
Case Objectives
Understand the importance of ongoing patient re-evaluati…
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psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
July 20, 2016 - A Potent Medication Administered in a Not So Viable Route
Citation Text:
Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
G…
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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/node/33626/psn-pdf
January 01, 2006 - In Conversation with…Jack Barker, PhD
January 1, 2006
In Conversation with…Jack Barker, PhD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withjack-barker-phd
Editor's Note: Jack Barker, PhD, is Vice President of Research and Development for Mach One
Leadership and a commercial pilot for …
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psnet.ahrq.gov/node/50696/psn-pdf
November 27, 2019 - Complications of Vascular Access Procedures in Patients
with Kidney Disease
November 27, 2019
Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
The Ca…
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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/49457/psn-pdf
September 01, 2004 - Doctor, Don't Treat Thyself
September 1, 2004
Rosvold EO. Doctor, Don't Treat Thyself. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
The Case
A 50-year-old radiologist presented to the emergency department of the community hospital where he
worked and reported increasing shortnes…
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psnet.ahrq.gov/node/49613/psn-pdf
November 01, 2010 - Mother's Milk, but Whose Mother?
November 1, 2010
Dougherty D. Mother's Milk, but Whose Mother? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
The Case
A 2-month-old otherwise healthy infant was admitted to the hospital to rule out sepsis. The infant had been
exclusively breastfed…
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psnet.ahrq.gov/node/49620/psn-pdf
February 01, 2011 - Silent Pain in the Neck
February 1, 2011
Bittner EA. Silent Pain in the Neck. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/silent-pain-neck
The Case
A 60-year-old man with no significant past medical history underwent an elective anterior cervical
discectomy for persistent right arm weakness due to cervi…
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psnet.ahrq.gov/web-mm/mistaken-identity
December 18, 2014 - Mistaken Identity
Citation Text:
Hall LW. Mistaken Identity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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…
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psnet.ahrq.gov/node/49426/psn-pdf
November 01, 2003 - Don't Push
November 1, 2003
Meltzer HY. Don't Push. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dont-push
The Case
A 37-year-old HIV-positive woman was brought to the emergency room by her family because she had
exhibited altered mentation for 3 days. The patient had been diagnosed with HIV infection 3 …
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psnet.ahrq.gov/node/49398/psn-pdf
May 01, 2003 - Bloody BP Cuff
May 1, 2003
Madan AK. Bloody BP Cuff. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/bloody-bp-cuff
The Case
Patient #1, a 28-year-old male, was a trauma patient following a motor vehicle collision into a cement pillar.
Patient #1 was in the trauma bay with massive injuries and profuse bleed…