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psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
February 01, 2012 - Repeat vital signs revealed a fever to 39.7°C and a heart rate of 121 beats per minute, concerning for
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - The hospitalist noted a heart rate of 75 beats per minute with a systolic blood pressure of 170 mmHg.
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psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.
Citation Text:
Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depa…
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Adverse Event During Intrahospital Transport
February 1, 2019
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
The Case
A 4-year-old boy underwent surgery under general anesthesia for correction o…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - Spotlight Case July 2008
Spotlight Case
Emergency Error
1
2
Source and Credits
This presentation is based on the June 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
October 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case October 2007
Do Not Disturb!
Source and Credits
This presentation is based on the October 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: F. Daniel Duffy, MD, University of Oklahoma, and…
-
psnet.ahrq.gov/node/49854/psn-pdf
February 01, 2019 - Diagnostic Failure: The Growing Deficit
February 1, 2019
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
The Case
A 65-year-old woman with a history of diabetes and hypertension was admitted to a hospital's telem…
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psnet.ahrq.gov/node/49796/psn-pdf
June 01, 2017 - Chest Tube Complications
June 1, 2017
Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/chest-tube-complications
The Case
A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for management of a
spontaneous left pneumothorax (coll…
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - lactate rose to 4.7
mmol/L (normal <2.0 mmol/L) and her oxygen requirements
increased to 3-4 liters/minute
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psnet.ahrq.gov/basic-page/ucd-cmeceu-trainee-certification
November 01, 2019 - University of California, Davis, Health CME/CEU Information
WebM&M Spotlight cases on AHRQ’s PSNet offer CME/CEU and Maintenance of Certification (MOC) credit. Effective November 2019, each Spotlight Case and Commentary is certified for the AMA PRA Category 1 ™and maintenance of certification (MOC) through the Amer…
-
psnet.ahrq.gov/node/49642/psn-pdf
December 01, 2011 - For example, within a 40-minute team meeting with the attending physician, seven
interruptions were
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - turned pale, became minimally responsive, and was found to have a respiratory rate of 5 breaths per minute
-
psnet.ahrq.gov/node/73650/psn-pdf
August 25, 2021 - After surgery, the patient
required about 2 liters/minute of oxygen by nasal cannula to prevent dyspnea
-
psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd
April 26, 2023 - RW : Or the minute it seems easy is the day you're dangerous again.
KS : Exactly, right.
-
psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - She was given IV fluids for tachycardia (heart rate 140 beats per minute [bpm]) and hypotension, with
-
psnet.ahrq.gov/node/846768/psn-pdf
March 29, 2023 - The oxygen is humidified and high gas flows up to 70 liters/minute are well tolerated
by patients.
-
psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - She was afebrile,
tachycardic (120 beats per minute), with a normal blood pressure (109/51) and excellent
-
psnet.ahrq.gov/web-mm/too-hot-comfort
May 19, 2015 - Too Hot For Comfort
Citation Text:
Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
July 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case July 2007
Resuscitation Errors:
A Shocking Problem
Source and Credits
This presentation is based on the July 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Benjamin Abella, MD, MPhil, …
-
psnet.ahrq.gov/node/33625/psn-pdf
January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions
Remain
January 1, 2006
Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
Perspective
On August 2, 2005, Air France flig…