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psnet.ahrq.gov/web-mm/no-blood-please
January 14, 2011 - No Blood, Please
Citation Text:
Liang BA. No Blood, Please. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
December 01, 2009 - Spotlight Case [MONTH] 2003
Spotlight Case
Standard Deviations
Source and Credits
This presentation is based on the December 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: James E. Sabin, MD
Harvard Medical School; Harvard Pilgrim Heal…
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psnet.ahrq.gov/node/49652/psn-pdf
May 01, 2012 - Double Dose at Transfer
May 1, 2012
Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/double-dose-transfer
The Case
A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department
(ED) for left lower extremity pain, swelling, and erythe…
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psnet.ahrq.gov/node/74021/psn-pdf
October 25, 2021 - In Conversation With... Georgia Galanou Luchen, Pharm.
D.
October 25, 2021
In Conversation With.. Georgia Galanou Luchen, Pharm. D. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-georgia-galanou-luchen-pharm-d
Editor’s Note: Georgia Galanou Luchen, Pharm. D., is the Director of Member Rela…
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - Electronic Err
Citation Text:
Tang PC. Electronic Err. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/49833/psn-pdf
June 01, 2018 - Perils in Diagnosing a Stroke
June 1, 2018
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
The Case
A 75-year-old man with a history of hypertension, diabetes, chronic back pain, and opioid use disorder was
brought to the emergency depart…
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psnet.ahrq.gov/node/49728/psn-pdf
March 01, 2015 - Medication Mix-Up: From Bad to Worse
March 1, 2015
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/medication-mix-bad-worse
The Case
A 69-year-old man with chronic kidney disease and essential hypertension was admitted to the hospital
with chest …
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psnet.ahrq.gov/node/49778/psn-pdf
December 01, 2016 - One Dose, Two Errors
December 1, 2016
Filice GA. One Dose, Two Errors. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/one-dose-two-errors
The Case
A 65-year-old woman was admitted to the intensive care unit (ICU) with severe sepsis and respiratory
failure secondary to community-acquired pneumonia. The pati…
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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - The Wrong Channel
September 1, 2005
Gosbee JW. The Wrong Channel . PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/wrong-channel
The Case
A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial
dosing started at 50 mL/hour using a multi-channel medication pump…
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psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
August 31, 2020 - Annual Perspective
Approach to Improving Patient Safety: Communication
March 10, 2021
View more articles from the same authors.
Citation Text:
Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. Ro…
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psnet.ahrq.gov/sites/default/files/2022-05/final_cme_reviewed_-_spotlight_missing_a_large_vessel_occlusion_stroke_04.14.2022_-_copy.pdf
January 01, 2022 - Spotlight
Spotlight
Missing a Large Vessel Occlusion Stroke in
a Patient with a History of Seizures
Source and Credits
• This presentation is based on the May 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: Kevin Keenan, MD and D…
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - improving quality for maternal health, behavioral health, kidney health and organ procurement programs, nursing … homes and long-term care, and prevention and wellness, among others.
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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - Sleep Deprivation Leads to Medication Error During
Spinal Epidural Anesthesia
August 30, 2023
Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-…
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psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx
Spotlight
Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full …
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psnet.ahrq.gov/web-mm/complaints-safety-surveillance
May 05, 2021 - Complaints as Safety Surveillance
Citation Text:
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
January 29, 2020 - Delayed Recognition of a Positive Blood Culture
Citation Text:
Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
July 02, 2019 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication
Citation Text:
Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/web-mm/bleeding-risk
November 01, 2003 - Bleeding Risk
Citation Text:
Crowther MA. Bleeding Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/node/49593/psn-pdf
October 01, 2009 - Who Nose Where the Airway Is?
October 1, 2009
Lee CR. Who Nose Where the Airway Is? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/who-nose-where-airway
The Case
A 70-year-old man with peripheral vascular disease was brought to the operating room to undergo vascular
bypass surgery on his right upper extrem…
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psnet.ahrq.gov/web-mm/amphotericin-toxicity
April 01, 2014 - Amphotericin Toxicity
Citation Text:
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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