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psnet.ahrq.gov/web-mm/discharging-our-responsibility
January 16, 2019 - education is left entirely until the day of hospital discharge, information saturation will likely occur
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psnet.ahrq.gov/web-mm/production-pressures
November 16, 2022 - Very often, changes in workload occur in health care in an unpredictable manner.
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psnet.ahrq.gov/web-mm/check-twice-transport-once
March 15, 2023 - Take Home Points
Medical errors can occur when patients are transported either within or between
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - medications can have adverse events, including genitourinary infections and eDKA. 4,5 eDKA with SGLT2i may occur
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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - However, a number of potential complications can occur over the entire life of the catheter if proper
-
psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - Decisions and behaviors are heavily influenced by the environment in which they occur.
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psnet.ahrq.gov/node/49840/psn-pdf
September 01, 2018 - Literature from the past 20 years has consistently shown that medication adverse events often occur
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psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
November 16, 2022 - surveillance software to proactively identify, investigate and mitigate nosocomial infections wherever they occur
-
psnet.ahrq.gov/node/33583/psn-pdf
March 01, 2023 - experience recognizing and responding to uncommon, high-risk, situations that might not otherwise occur
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - SPOTLIGHT CASE
Fatal Error in Neonate: Does "Just Culture" Provide an Answer?
Citation Text:
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. …
-
psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
January 01, 2020 - Spotlight
Spotlight
Inpatient Stroke Management in a Patient
with Type 1 Diabetes and Home Insulin
Pump
Source and Credits
• This presentation is based on the October 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Berit B…
-
psnet.ahrq.gov/node/49617/psn-pdf
January 01, 2011 - Failure to Reevaluate
December 1, 2010
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/failure-reevaluate
The Case
A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community
hospital developed methicillin-resistant staphylococc…
-
psnet.ahrq.gov/node/49471/psn-pdf
December 01, 2004 - Carpe Diem (Seize the Day)
December 1, 2004
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day
The Case
A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic
medical conditions including hypertension, h…
-
psnet.ahrq.gov/node/857060/psn-pdf
November 27, 2023 - The Role of Undergraduate Nursing Education in Patient
Safety
November 27, 2023
Stanley J, Gale B, Mossburg S. The Role of Undergraduate Nursing Education in Patient Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
Introduction
Nurses are a li…
-
psnet.ahrq.gov/node/49740/psn-pdf
August 21, 2015 - Baffled by Botulinum Toxin
August 21, 2015
Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
The Case
A 5-year-old boy with a history of transverse myelitis with resultant spasticity of both lower extremities, gait
abnormalities, neurogeni…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
April 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case April 2008
Antibiotics for URI/Sinusitis: A Simple Decision Gone Bad
Source and Credits
This presentation is based on the April 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Sumant Ranji, MD,…
-
psnet.ahrq.gov/node/49456/psn-pdf
July 12, 2004 - Glucose Roller Coaster
July 1, 2004
Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/glucose-roller-coaster
The Case
A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was
significant for dialysis-dependent, end-stage kidney d…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
August 01, 2012 - Spotlight Case
Spotlight Case
No News May Not Be Good News
1
2
Source and Credits
This presentation is based on the August 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…
-
psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…
-
psnet.ahrq.gov/node/49487/psn-pdf
August 21, 2005 - Surprise Wire
August 21, 2005
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/surprise-wire
The Case
A 39-year-old man with a history of liver disease presented to the emergency department (ED) with
gastrointestinal bleeding and altered mental status. Due to his clinic…