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psnet.ahrq.gov/perspective/conversation-dave-debronkartJune 01, 2014 - generally concentrated their efforts on hospitals, where the most devastating patient injuries are seen as occurring
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49614/psn-pdfNovember 01, 2010 - Reconciling Records November 1, 2010 Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/reconciling-records The Cases Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local teaching hospital. When discharged, h… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49796/psn-pdfJune 01, 2017 - Chest Tube Complications June 1, 2017 Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/chest-tube-complications The Case A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for management of a spontaneous left pneumothorax (coll… -
Spotlight Case [MONTH] 2003 (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.158_slideshow.pptSeptember 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case September 2007 Medication Reconciliation: Whose Job Is It? Source and Credits This presentation is based on the September 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Eric G. Poon, MD, MPH, Ha… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33633/psn-pdfMay 01, 2006 - Patient Safety in the Physician Office Setting May 1, 2006 Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting Perspective Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49622/psn-pdfMarch 01, 2011 - Dropping the Ball Despite an Integrated EMR March 1, 2011 Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr The Case A patient followed at a community-based clinic that is part of a large health care system with an in… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33705/psn-pdfJanuary 01, 2011 - Risk Management and Patient Safety December 1, 2010 Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety Perspective In 1990, a Harvard-based research team reported the incidence of medical errors … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49661/psn-pdfAugust 01, 2012 - Residual Anesthesia: Tepid Burn August 1, 2012 Kurrek MM, Twersky RS. Residual Anesthesia: Tepid Burn. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn The Case A 42-year-old Filipino man presented to an outpatient surgery center for scheduled repair of an anal fistula. The pat… -
Spotlight Case July 2008 (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.278_slideshow.pptSeptember 01, 2012 - Spotlight Case July 2008 Spotlight Case Peripheral IV in Too Long 1 2 Source and Credits This presentation is based on the September 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Chi-Tai Fang, MD, PhD; Associate Professor, National Taiwan Uni… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33813/psn-pdfAugust 01, 2016 - Safety In Dentistry August 1, 2016 Ramoni R, Walji MF, Kalenderian E. Safety In Dentistry. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/safety-dentistry Perspective In a famous scene from the 1976 film, Marathon Man, Laurence Olivier, playing dentist Dr. Christian Szell tortures Babe Levy (played by… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49502/psn-pdfFebruary 01, 2006 - Deciphering the Code February 1, 2006 Goldstein MK. Deciphering the Code. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/deciphering-code The Case An 85-year-old man with advanced oxygen-dependent chronic obstructive pulmonary disease (COPD) presented to the emergency department (ED) with increasing shortn… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33838/psn-pdfJuly 01, 2017 - Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? July 1, 2017 Studdert DM. Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49391/psn-pdfFebruary 01, 2003 - When "Psychiatric" Symptoms Are Not February 1, 2003 Goldberg RJ. When "Psychiatric" Symptoms Are Not. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not The Case A 70-year-old man without documented past psychiatric history was placed on an involuntary hold as a danger to oth… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49836/psn-pdfJuly 01, 2018 - Primary Workaround, Secondary Complication July 1, 2018 Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication The Case A young adult with a progressive neurological disorder presented to a hospital emerg… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49533/psn-pdfMarch 01, 2007 - Staggered Sensitivity Results March 1, 2007 Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/staggered-sensitivity-results The Case A 60-year-old woman with squamous cell carcinoma of the glottis underwent laryngectomy, anterior neck dissection, and pectoralis fla… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49655/psn-pdfJune 01, 2012 - A Painful Dilemma June 1, 2012 Davison SN. A Painful Dilemma. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/painful-dilemma The Case A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with fever. She was taking propoxyphene or hydrocodone at home for pain. She h… -
Spotlight (pdf file)
psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdfJanuary 01, 2020 - Spotlight Spotlight Discharged with IV antibiotics: When issues arise, who manages the complications? Source and Credits • This presentation is based on the February 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Monica Donnel… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49772/psn-pdfOctober 01, 2016 - Lapse in Antibiotics Leads to Sepsis October 1, 2016 Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis The Case A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal pain, fevers, and short… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33719/psn-pdfOctober 01, 2011 - The Context Is the Intervention October 1, 2011 Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/context-intervention Perspective Introduction What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this context.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49756/psn-pdfApril 01, 2016 - Lost in Sign Out and Documentation April 1, 2016 Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation The Case A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the emergency physician, …
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