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  1. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences | PSNet

    psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
    December 18, 2019 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences Citation Text: Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60168/psn-pdf
    March 25, 2020 - Right Electrocardiogram, Wrong Patient March 25, 2020 Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient The Cases Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49473/psn-pdf
    March 01, 2005 - On O.R. Off? March 1, 2005 Leonard M. On O.R. Off? PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/or The Case An elderly man was admitted to the vascular surgery service with rest pain in his leg. Angiography demonstrated peripheral artery disease with anatomy suitable for revascularization. A consulting …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49551/psn-pdf
    December 01, 2007 - Too Hot For Comfort December 1, 2007 Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/too-hot-comfort The Case A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV antibiotics via a peripheral line in the left antec…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849660/psn-pdf
    May 31, 2023 - Strategies to Improve Organizational Health Literacy. May 31, 2023 Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy Background Health literacy is important at both the personal …

  6. Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study. | PSNet

    psnet.ahrq.gov/issue/characteristics-morbidity-and-mortality-conferences-associated-implementation-patient-safety
    March 18, 2020 - multidisciplinary medication review on the safety and medication cost of the elderly people living in a nursing … home: a before-after study.

  7. A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion | PSNet

    psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
    June 14, 2023 - SPOTLIGHT CASE A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion Citation Text: Duong T, Boctor N, Bourgeois JA. A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality…

  8. A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study. | PSNet

    psnet.ahrq.gov/issue/partially-structured-postoperative-handoff-protocol-improves-communication-2-mixed-surgical
    November 19, 2018 - Study A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study. Citation Text: Lane-Fall MB, Pascual JL, Peifer HG, et al. A Partia…

  9. A comparative effectiveness analysis of the implementation of surgical safety checklists in a tertiary care hospital. | PSNet

    psnet.ahrq.gov/issue/comparative-effectiveness-analysis-implementation-surgical-safety-checklists-tertiary-care
    December 20, 2023 - Study A comparative effectiveness analysis of the implementation of surgical safety checklists in a tertiary care hospital. Citation Text: Bock M, Fanolla A, Segur-Cabanac I, et al. A Comparative Effectiveness Analysis of the Implementation of Surgical Safety Checklists in a Tertiary Car…

  10. A prospective controlled trial of an electronic hand hygiene reminder system. | PSNet

    psnet.ahrq.gov/issue/prospective-controlled-trial-electronic-hand-hygiene-reminder-system
    April 07, 2021 - Study A prospective controlled trial of an electronic hand hygiene reminder system. Citation Text: Ellison RT, Barysauskas CM, Rundensteiner EA, et al. A Prospective Controlled Trial of an Electronic Hand Hygiene Reminder System. Open Forum Infect Dis. 2015;2(4):ofv121. doi:10.1093/ofid/…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866578/psn-pdf
    August 28, 2024 - Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy August 28, 2024 Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insul…

  12. The Forgotten Turn | PSNet

    psnet.ahrq.gov/web-mm/forgotten-turn
    August 01, 2018 - SPOTLIGHT CASE The Forgotten Turn Citation Text: Barbour S. The Forgotten Turn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72517/psn-pdf
    November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. November 25, 2020 Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesare…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60977/psn-pdf
    January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication September 30, 2020 Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication The Case A 65-year-old woman co…

  15. Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx Spotlight Respiratory Distress after Neck Surgery: Two Cases of Post-Operative Cervical Hematoma Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73334/psn-pdf
    August 01, 2024 - An Inadvertent Bolus of Norepinephrine. May 26, 2021 Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counc…

  17. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. | PSNet

    psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
    March 15, 2023 - SPOTLIGHT CASE False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. Citation Text: Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49656/psn-pdf
    June 01, 2012 - Comanagement: Who's in Charge? June 1, 2012 Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/comanagement-whos-charge The Case A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left hip fracture to the orthopedic surg…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49527/psn-pdf
    December 01, 2006 - Right Patient, Wrong Sample December 1, 2006 Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample The Case A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On the morning of surgery, the patien…

  20. Severe illness getting noticed sooner - SIGNS-for-Kids: developing an illness recognition tool to connect home and hospital. | PSNet

    psnet.ahrq.gov/issue/severe-illness-getting-noticed-sooner-signs-kids-developing-illness-recognition-tool-connect
    September 23, 2020 - Study Severe illness getting noticed sooner - SIGNS-for-Kids: developing an illness recognition tool to connect home and hospital. Citation Text: Gilleland J, Bayfield D, Bayliss A, et al. Severe illness getting noticed sooner – SIGNS-for-Kids: developing an illness recognition tool to c…
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