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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74713/psn-pdf
    January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking January 26, 2022 Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking Disclosure of Relevant Financial Relationships: As a provider ac…
  2. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
    January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
  3. psnet.ahrq.gov/web-mm/weighing-surgical-safety
    August 04, 2021 - SPOTLIGHT CASE Weighing In on Surgical Safety Citation Text: Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar …
  4. psnet.ahrq.gov/web-mm/volume-too-low-and-out
    July 01, 2017 - SPOTLIGHT CASE Volume Too Low: In and Out Citation Text: Miller MR. Volume Too Low: In and Out . 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 XM…
  5. psnet.ahrq.gov/web-mm/hidden-mystery
    December 01, 2011 - SPOTLIGHT CASE Hidden Mystery Citation Text: Brunette DD. Hidden Mystery. 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 …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865455/psn-pdf
    March 27, 2024 - Communication During Transitions of Care March 27, 2024 Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/communication-during-transitions-care Introduction Inaccurate or untimely communication and ineffective teamwork in healthca…
  7. psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
    May 01, 2008 - SPOTLIGHT CASE A Painful Medication Reconciliation Mishap Citation Text: Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google S…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842919/psn-pdf
    February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis. February 1, 2023 Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis The Cases Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73642/psn-pdf
    August 25, 2021 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected August 25, 2021 Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect- unexpected …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49486/psn-pdf
    August 21, 2005 - Impatient Inpatient Dosing August 21, 2005 White RH. Impatient Inpatient Dosing. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/impatient-inpatient-dosing Case Objectives Appreciate the challenges of initiating warfarin therapy in the hospitalized patient Understand the fundamental pharmacology of warfarin…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49624/psn-pdf
    May 01, 2011 - Duty to Disclose Someone Else's Error? May 1, 2011 Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error Case Objectives State the rationale for disclosing medical errors. Describe key principles in effective error disclosure. …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837660/psn-pdf
    July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse Outcomes July 8, 2022 Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes The Cases Case 1: A 64-year-old man came in for a routine bron…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33732/psn-pdf
    July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP July 1, 2012 In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp Editor's note: David Blumenthal, MD, MPP, is Chief Health Information and Innovation Officer, Partners Healt…
  14. psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx Spotlight Respiratory Distress after Neck Surgery: Two Cases of Post-Operative Cervical Hematoma Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49388/psn-pdf
    February 01, 2003 - Unexplained Apnea Under Anesthesia February 1, 2003 Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia Case Objectives Clinical Objectives List the causes of prolonged apnea in the operating room Describe the steps in management …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33734/psn-pdf
    August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD August 1, 2012 In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd Editor's note: The topic of patient safety in long-term care facilities has not received the attent…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49474/psn-pdf
    March 01, 2005 - Hidden Mystery March 1, 2005 Brunette DD. Hidden Mystery. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/hidden-mystery Case Objectives Appreciate the challenges of caring for morbidly obese patients. List specific interventions that can be implemented when caring for obese patients. Develop a rational ap…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74021/psn-pdf
    October 25, 2021 - In Conversation With... Georgia Galanou Luchen, Pharm. D. October 25, 2021 In Conversation With.. Georgia Galanou Luchen, Pharm. D. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-georgia-galanou-luchen-pharm-d Editor’s Note: Georgia Galanou Luchen, Pharm. D., is the Director of Member Rela…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33837/psn-pdf
    July 01, 2017 - In Conversation With… Michelle Mello, MPhil, JD, PhD July 1, 2017 In Conversation With… Michelle Mello, MPhil, JD, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd Editor's note: Michelle Mello is Professor of Law at Stanford Law School and Professor of Healt…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49861/psn-pdf
    May 01, 2019 - Updates in the Management of High-Risk Pulmonary Embolism May 1, 2019 Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism Case Objectives Review common risk factors, typical present…

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