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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Duplicate Therapies in Retail Pharmacy
March 15, 2023
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
The Cases
Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection f…
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging
Citation Text:
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Fo…
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - Missed CANDOR Implementation Opportunities.
Citation Text:
Schweitzer L. Missed CANDOR Implementation Opportunities.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/73103/psn-pdf
March 31, 2021 - Delayed Diagnosis in the Setting of Virtual Care:
Remembering the Physical Examination
March 31, 2021
Valdes W, Utter GH. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical
Examination. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-…
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking
January 26, 2022
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
Disclosure of Relevant Financial Relationships: As a provider ac…
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Patient Safety Events Involving Opioid
Dose Stacking
Source and Credits
• This presentation is based on the January 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: Hollie Porras, PharmD, BCPS and Cathy Lammers…
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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
September 25, 2024 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected
Citation Text:
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - SPOTLIGHT CASE
Moving Pains
Citation Text:
Schell H, Wachter R. Moving Pains. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - SPOTLIGHT CASE
The Safety and Quality of Long Term Care
Citation Text:
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Goog…
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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound
and Patient Safety
July 1, 2018
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
Case Objectives
Unders…
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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/node/74121/psn-pdf
November 30, 2021 - Hidden Danger! Insidious Postpartum Bleeding After
Emergency Cesarean Delivery.
November 30, 2021
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean
Delivery. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emerg…
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psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - Nothing Called Small Surgery
Citation Text:
Manske C. Nothing Called Small Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination
April 29, 2020 - Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination
Citation Text:
Valdes W, Utter GH. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Hea…
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - SPOTLIGHT CASE
Patient Safety Events Involving Opioid Dose Stacking
Citation Text:
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - Duplicate Therapies in Retail Pharmacy
Citation Text:
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
Google Scholar BibTeX E…
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psnet.ahrq.gov/node/50613/psn-pdf
October 30, 2019 - In Conversation With… Neel Shah, MD, MPP
October 30, 2019
In Conversation With… Neel Shah, MD, MPP. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp
Editor's note: Dr. Shah, MD, MPP, is an Assistant Professor of Obstetrics, Gynecology and Reproductive
Biology at Harvard Medi…
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psnet.ahrq.gov/node/846169/psn-pdf
March 15, 2023 - Distraction of the Anesthesiologist and Lack of
Resuscitation Drugs Resulting in Delayed Treatment of
Laryngospasm.
March 15, 2023
Bohringer C. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed
Treatment of Laryngospasm. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/…
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psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
January 29, 2021 - An Incomplete Anesthesia History Leads to Adverse Outcomes
Citation Text:
Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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…
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Spotlight
Spotlight
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
1
Source and Credits
This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Samantha Brown…