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  1. psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
    November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures Citation Text: Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
  2. psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
    August 20, 2018 - A Double “Never Event”: Wrong Patient and Wrong Side. Citation Text: Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49651/psn-pdf
    May 01, 2012 - The Perils of Cross Coverage May 1, 2012 Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/perils-cross-coverage Case Objectives Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and care transitions. Describe ed…
  4. psnet.ahrq.gov/web-mm/errors-sepsis-management
    November 03, 2015 - SPOTLIGHT CASE Errors in Sepsis Management Citation Text: Shimabukuro D. Errors in Sepsis Management. 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 X…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49648/psn-pdf
    March 01, 2012 - Postdischarge Follow-Up Phone Call March 1, 2012 Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call Case Objectives Understand why preventing readmissions through postdischarge phone calls is important. Describe evidence su…
  6. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
    January 01, 2022 - Spotlight Spotlight Delayed Diagnosis of Mesenteric Ischemia Source and Credits • This presentation is based on the August 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: Anamaria Robles, MD, and Garth Utter, MD, MSc o AHRQ WebM&M…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49618/psn-pdf
    February 01, 2011 - One Toxic Drug Is Not Like Another February 1, 2011 Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/one-toxic-drug-not-another Case Objectives Distinguish between the three distinct regulatory processes of board certification, medical licensure, and credential…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49478/psn-pdf
    April 01, 2005 - Compare and Contrast April 1, 2005 Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/compare-and-contrast Case Objectives Define contrast nephropathy (CN) List risk factors for CN Implement pharmacologic strategies for CN prophylaxis Follow an algorithm for CN risk …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60865/psn-pdf
    August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA- BC-FACHE August 31, 2020 In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache Editor’s Note: Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863308/psn-pdf
    February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy February 28, 2024 Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy The Case A…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49735/psn-pdf
    June 01, 2015 - Anchoring Bias With Critical Implications June 1, 2015 Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications Case Objectives Appreciate that diagnostic errors are common in primary and ambulatory care. Define premature clo…
  12. 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 …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49758/psn-pdf
    April 01, 2016 - Dropping to New Lows April 1, 2016 Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/dropping-new-lows Case Objectives State how to manage diabetes medications when patients are admitted to the hospital Describe a guideline-recommended insulin regimen for a hospitaliz…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49834/psn-pdf
    July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety July 1, 2018 Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety Case Objectives Unders…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49840/psn-pdf
    September 01, 2018 - Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care September 1, 2018 Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adver…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49636/psn-pdf
    October 01, 2011 - Mobility Lost in the ICU October 1, 2011 Smith J. Mobility Lost in the ICU. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/mobility-lost-icu Case Objectives Describe the role of the physical therapist in the hospital and ICU. Compare the risks from immobility with the benefits gained from a program of ther…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49708/psn-pdf
    May 01, 2014 - Medication Reconciliation With a Twist (or Dare We Say, a Patch?) May 1, 2014 Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch Case Objectives Appreciate that medication discrepanc…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49738/psn-pdf
    August 21, 2015 - Privacy or Safety? August 21, 2015 Halamka JD, McGraw D. Privacy or Safety? PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/privacy-or-safety Case Objectives Understand that the HIPAA Omnibus Rule is an enabler of data sharing, not a barrier. Review common misconceptions about privacy rules. Understand the…
  19. psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
    October 31, 2023 - SPOTLIGHT CASE Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. Citation Text: Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…
  20. psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
    January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging Citation Text: Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…

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