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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - pulmonologists who frequently administer immune suppressive medications, should keep Strongyloides in mind
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psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
September 01, 2017 - It may be helpful to keep in mind the suggestion from neuroscience that " f eelings are mental experiences
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - When illegibility raises doubt in a pharmacist's mind, the pharmacist may seek clarification by viewing
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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - the Same Author(s)
WebM&M Cases
Out of Sight, Out of Mind
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psnet.ahrq.gov/curated-library/value-and-patient-safety
October 30, 2019 - range of different care improvement projects, including safety initiatives, with this framework in mind
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psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
February 26, 2025 - In Conversation With… Timothy B. McDonald, MD, JD
April 1, 2019
Citation Text:
In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy C…
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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…
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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…
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - Debriefing for Clinical Learning
November 18, 2021
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/debriefing-clinical-learning
Updated in September 2021. Originally published in December 2011 by researchers at the University of
California, S…
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - Missed CANDOR Implementation Opportunities.
Citation Text:
Schweitzer L. Missed CANDOR Implementation Opportunities.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Format:
Google Scholar BibTeX EndN…
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psnet.ahrq.gov/web-mm/pregnant-danger
January 12, 2011 - disorder in a woman of childbearing age, it is a potentially lethal condition and so it should be kept in mind
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
February 22, 2023 - that might similarly prompt a clinician to consider clinical contexts that may not first spring to mind
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - Clinicians therefore need to maintain an open mind about the accuracy of their initial diagnosis.
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - of hospital quality measures is typically undertaken with a number of explicit and implicit aims in mind
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - The most important thing to keep in mind is that suicide risk is highest when multiple risk factors coexist
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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - require significant financial investment, and must be implemented with the entire health
system in mind
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - Dying in the Hospital With Advanced Dementia
December 1, 2017
A piece of my mind
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - It is important to keep in mind that oxygen saturation can be falsely normal in the setting of supplemental
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - require significant financial investment, and must be implemented with the entire health system in mind
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - SPOTLIGHT CASE
Patient Safety Events Involving Opioid Dose Stacking
Citation Text:
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
Copy Cita…