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  1. Volume Too Low: In and Out | PSNet

    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…

  2. Hidden Mystery | PSNet

    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 …

  3. Diagnosing Diagnostic Mistakes | PSNet

    psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
    April 30, 2014 - SPOTLIGHT CASE Diagnosing Diagnostic Mistakes Citation Text: McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google S…

  4. Transfer Troubles | PSNet

    psnet.ahrq.gov/web-mm/transfer-troubles
    December 29, 2014 - SPOTLIGHT CASE Transfer Troubles Citation Text: Hains IM. Transfer Troubles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50611/psn-pdf
    October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing October 30, 2019 Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing Case Objectives List the most common errors associated with computerized…

  6. A Painful Medication Reconciliation Mishap | PSNet

    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…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49519/psn-pdf
    September 01, 2006 - Triple Handoff September 1, 2006 Vidyarthi A. Triple Handoff. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/triple-handoff Case Objectives Appreciate the prevalence of handoffs and sign out related errors. Understand the key elements of a safe and effective written and verbal sign out. List Kotter’s 8 st…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49852/psn-pdf
    February 01, 2019 - Triaging Interhospital Transfers February 1, 2019 Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/triaging-interhospital-transfers Case Objectives Recognize that transfer of patients between acute care hospitals is common. Realize that the interhospital transfer…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49579/psn-pdf
    March 21, 2009 - All in the History March 21, 2009 Fee C. All in the History. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/all-history Case Objectives Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it does not apply to transfers to emergency departments from non-acute care faci…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49690/psn-pdf
    September 01, 2013 - The Pains of Chronic Opioid Usage September 1, 2013 Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage Case Objectives Describe the appropriate initial assessment of patients with chronic non-cancer pain. List the most comm…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49744/psn-pdf
    October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy October 1, 2015 Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…

  12. Errors in Sepsis Management | PSNet

    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…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49675/psn-pdf
    February 01, 2013 - Delay in Treatment: Failure to Contact Patient Leads to Significant Complications February 1, 2013 Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complicat…

  14. 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…

  15. 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…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49858/psn-pdf
    April 01, 2019 - What Happened on Telemetry? April 1, 2019 Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/what-happened-telemetry Case Objectives Describe current hospital practices for continuous telemetry monitoring. Appreciate key recommendations from the Update to Practice…

  17. 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…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43204/psn-pdf
    May 21, 2014 - Be an Active Member of Your Health Care Team. May 21, 2014 US Food and Drug Administration; FDA. https://psnet.ahrq.gov/issue/be-active-member-your-health-care-team This fact sheet describes five ways patients can contribute to and ensure safe medication use, including speaking up about medical history, asking que…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33876/psn-pdf
    August 01, 2018 - tenets of a just culture.(11) Examples of other approaches may include publicly celebrating staff members

  20. Mortality trends after a voluntary checklist-based surgical safety collaborative. | PSNet

    psnet.ahrq.gov/issue/mortality-trends-after-voluntary-checklist-based-surgical-safety-collaborative
    September 24, 2017 - September 24, 2017 Introductions during time-outs: do surgical team members know one
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