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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - SPOTLIGHT CASE
Cognitive Overload in the ICU
Citation Text:
Patel VL, Buchman TG. Cognitive Overload in the ICU. 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/node/849679/psn-pdf
June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
June 28, 2023
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue
Necrosis and Cuff Rupture. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…
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psnet.ahrq.gov/web-mm/double-dose-transfer
November 01, 2012 - Double Dose at Transfer
Citation Text:
Hackman JL. Double Dose at Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - Benefits vs. Risks of Intraosseous Vascular Access
August 21, 2014
Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
The Case
A 72-year-old woman with a history of asthma, congestive heart…
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psnet.ahrq.gov/node/49420/psn-pdf
October 01, 2003 - To LP or Not LP
October 1, 2003
Landrigan CP. To LP or Not LP. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/lp-or-not-lp
The Case
A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with
fever and irritability without an obvious source. He was referred to …
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psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Check the Anesthesia Machine
December 1, 2013
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/check-anesthesia-machine
The Case
A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension,
diabetes, sleep apnea…
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psnet.ahrq.gov/node/60330/psn-pdf
May 05, 2020 - Telehealth and Patient Safety During the COVID-19
Response
May 14, 2020
Sikka N, Willis JS, Fitall E, et al. Telehealth and Patient Safety During the COVID-19 Response. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
Introduction
Telehealth typ…
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psnet.ahrq.gov/web-mm/painful-dilemma
September 01, 2013 - A Painful Dilemma
Citation Text:
Davison SN. A Painful Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.323_slideshow.ppt
May 01, 2014 - PowerPoint Presentation
Spotlight
Medication Reconciliation With a Twist (or Dare We Say, a Patch?)
This presentation is based on the May 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Janice Kwan, MD, Department of Medicine, University of Tor…
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psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
November 21, 2021 - Lapse in Antibiotics Leads to Sepsis
Citation Text:
Levy MM. Lapse in Antibiotics Leads to Sepsis. 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/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-improves-maternal-and
September 23, 2024 - Safety Innovations
Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing … Home Residents
July 28, 2021
Patient Safety Innovations
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - Baffled by Botulinum Toxin
Citation Text:
Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/50612/psn-pdf
October 30, 2019 - The Safety Challenges of Supervision and Night Coverage
in Academic Residency
October 30, 2019
Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
The Case…
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psnet.ahrq.gov/node/49620/psn-pdf
February 01, 2011 - Silent Pain in the Neck
February 1, 2011
Bittner EA. Silent Pain in the Neck. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/silent-pain-neck
The Case
A 60-year-old man with no significant past medical history underwent an elective anterior cervical
discectomy for persistent right arm weakness due to cervi…
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psnet.ahrq.gov/node/33721/psn-pdf
November 01, 2011 - Lesson from the VA's Team Training Program
November 1, 2011
Neily J, Mills PD, Paull DE, et al. Lesson from the VA's Team Training Program . PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/lesson-vas-team-training-program
Perspective
Introduction
The Veterans Health Administration (VHA) National Center…
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psnet.ahrq.gov/web-mm/2-week-itch
June 16, 2019 - The 2-Week Itch
Citation Text:
Cohen MR. The 2-Week Itch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
January 01, 2008 - In Conversation with…Jennifer Daley, MD
January 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Jennifer Daley, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Co…
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psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
January 01, 2008 - Implementing a Patient Safety Program at a Large National Health System
Loran Hauck, MD, and Jan Jacob, MBA, RN | January 1, 2008
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Hauck LD, Jacob J. Implementing a Patient Safety …
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture.
Citation Text:
Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…
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psnet.ahrq.gov/node/50614/psn-pdf
October 30, 2019 - In Conversation With… Vineet Chopra, MD, MSc
October 30, 2019
In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
Editor's note: Dr. Chopra is Chief of the Division of Hospital Medicine and Associate Professor of
Medicine at the…