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psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
October 19, 2022 - SPOTLIGHT CASE
Resuscitation Errors: A Shocking Problem
Citation Text:
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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…
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psnet.ahrq.gov/node/49588/psn-pdf
August 01, 2009 - Nurse Staffing Ratios: The Crucible of Money, Policy,
Research, and Patient Care
August 1, 2009
Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
Case…
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psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
November 15, 2023 - Complications of Vascular Access Procedures in Patients with Kidney Disease
Citation Text:
Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/node/49540/psn-pdf
August 21, 2007 - Resuscitation Errors: A Shocking Problem
August 21, 2007
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
Case Objectives
Appreciate that delays in defibrillation can have significant negative effects on sur…
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psnet.ahrq.gov/web-mm/transfer-or-not-transfer
November 23, 2016 - SPOTLIGHT CASE
To Transfer or Not to Transfer
Citation Text:
Pines JM. To Transfer or Not to Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
February 26, 2025 - In Conversation With… Ann L. Hendrich, RN, PhD
December 1, 2011
Citation Text:
In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/49816/psn-pdf
January 01, 2018 - A Painful Medication Reconciliation Mishap
January 1, 2018
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
Case Objectives
Recognize that substance use disorders are common in patients with acute pain.
Understand th…
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psnet.ahrq.gov/node/33738/psn-pdf
December 01, 2012 - In Conversation With... John G. Reiling, PhD
December 1, 2012
In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
Editor's note: John G. Reiling, PhD, is president and CEO of Safe by Design. Dr. Reiling consults with
hospitals and…
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psnet.ahrq.gov/node/49455/psn-pdf
July 01, 2004 - The Worst Headache
July 1, 2004
Edlow JA. The Worst Headache. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/worst-headache
The Case
A 48-year-old woman with a history of migraine headaches and hypertension presented to her outpatient
clinic with a 4-day history of headache. While shopping 4 days earlier, …
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psnet.ahrq.gov/node/49549/psn-pdf
December 06, 2007 - Elopement
December 1, 2007
Gerardi D. Elopement. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/elopement
Case Objectives
Define elopement and differentiate it from wandering and leaving against medical advice.
Identify leading contributors to elopement events.
Describe strategies for preventing elopement…
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psnet.ahrq.gov/node/33746/psn-pdf
March 01, 2013 - In Conversation With… David M. Gaba, MD
March 1, 2013
In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of
Medicine. An international leade…
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psnet.ahrq.gov/node/49608/psn-pdf
August 01, 2010 - Emergent Triage Miss
August 1, 2010
Travers D. Emergent Triage Miss. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/emergent-triage-miss
The Case
A 42-year-old woman presented to a busy urban emergency department (ED) and approached the triage
nurse. The patient told the triage nurse that she had "3 days o…
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic
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April 27, 2022
Innovation
Conta…
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psnet.ahrq.gov/node/33635/psn-pdf
July 01, 2006 - In Conversation with...Allan Frankel, MD
July 1, 2006
In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this
kind of work.
Dr. Allan …
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psnet.ahrq.gov/node/49543/psn-pdf
September 01, 2007 - Medication Reconciliation: Whose Job Is It?
September 1, 2007
Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
Case Objectives
Appreciate the prevalence and impact of medication discrepancies at times of transition in …
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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - Multifactorial Medication Mishap
February 1, 2014
Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
Case Objectives
Understand the system-based causes of medication errors.
Describe a model for a systems approach to error analysis.
Id…
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Getting the Diagnosis Both Right and Wrong
Citation Text:
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/49584/psn-pdf
April 01, 2009 - EMR Entry Error: Not So Benign
April 1, 2009
Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
The Case
A 47-year-old man with advanced AIDS was admitted to an academic medical center with a chief complaint
of shortness of breath. He was …
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psnet.ahrq.gov/node/33664/psn-pdf
March 01, 2008 - In Conversation with...Bradley T. Rosen, MD, MBA
March 1, 2008
In Conversation with..Bradley T. Rosen, MD, MBA. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
Editor's note: Dr. Rosen is Medical Director of the Inpatient Specialty Program (ISP) Hospitalist service…
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psnet.ahrq.gov/node/33849/psn-pdf
January 01, 2018 - In Conversation With… Robert Hirschtick, MD
January 1, 2018
In Conversation With… Robert Hirschtick, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
Editor's note: Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author
of a numbe…