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  1. 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
  2. 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.
  3. 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…
  4. Psn-Pdf (pdf file)

    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…
  5. 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…
  6. 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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. 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
  10. 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…
  11. Psn-Pdf (pdf file)

    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
  12. 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
  13. Psn-Pdf (pdf file)

    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
  14. 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.
  15. 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
  16. Psn-Pdf (pdf file)

    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.
  17. Psn-Pdf (pdf file)

    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
  18. 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…
  19. 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, …
  20. Psn-Pdf (pdf file)

    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…

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