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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - cisplatin were close together on the ordering screen, making it easy to accidentally enter the wrong option
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psnet.ahrq.gov/node/49661/psn-pdf
August 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…
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psnet.ahrq.gov/node/49835/psn-pdf
January 01, 2020 - Don't Pick the PICC
July 1, 2018
McGill RL. Don't Pick the PICC. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/dont-pick-picc
The Case
A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy;
glaucoma; and stage IV chronic kidney disease was admitted to the hospita…
-
psnet.ahrq.gov/node/49577/psn-pdf
January 01, 2009 - stay.(4) These recommendations attempt to
balance safety concerns with a desire to allow patients the option
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psnet.ahrq.gov/node/33634/psn-pdf
May 04, 2006 - Improved state regulation
with tough licensing laws is one important option.
-
psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx
Spotlight
A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion
Source and Credits
• This presentation is based on the July 2023 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
-
psnet.ahrq.gov/node/72586/psn-pdf
December 23, 2020 - they can still have rational reasons specific to their own
preferences for forgoing the recommended option
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psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room.
Citation Text:
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. 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/846126/psn-pdf
March 09, 2023 - Medication Handling and Compounding Errors in the
Operating Room.
March 15, 2023
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating
Room. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
The Case
A 62-y…
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psnet.ahrq.gov/web-mm/saved-ecmo
May 05, 2017 - administrations. 3
While the choice of anesthesia in this case was appropriate and was likely the safest option
-
psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - Complaints as Safety Surveillance
September 1, 2016
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance
The Case
A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain
came on sudden…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.182_slideshow.ppt
September 01, 2008 - Spotlight Case July 2008
Spotlight Case
Empiric Steroids: the Good, the Bad, and the Ugly
Source and Credits
This presentation is based on the September 2008 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Edward D. Harris, Jr, MD, Stanford U…
-
psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
December 18, 2019 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences
Citation Text:
Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…
-
psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
January 01, 2024 - Spotlight
Spotlight
Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis
1
Source and Credits
This presentation is based on the December 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Comment…
-
psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
June 14, 2023 - SPOTLIGHT CASE
CME/MOC
A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion
Citation Text:
Duong T, Boctor N, Bourgeois JA. A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.. PSNet [internet]. Rockville (MD): Agency for H…
-
psnet.ahrq.gov/node/851568/psn-pdf
July 31, 2023 - A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion
July 31, 2023
Duong T, Boctor N, Bourgeois JA. A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomid…
-
psnet.ahrq.gov/node/837658/psn-pdf
July 08, 2022 - unfortunately, they failed to document and write orders for
hospice in the chart leaving the nursing staff no option
-
psnet.ahrq.gov/node/836976/psn-pdf
April 27, 2022 - vascular access.5 Because IO access can be
performed rapidly, it is an acceptable and valuable second option … but if such access is difficult, delayed, or not possible,
an IO line is an acceptable second line option
-
psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
September 29, 2021 - vascular access. 5 Because IO access can be performed rapidly, it is an acceptable and valuable second option … but if such access is difficult, delayed, or not possible, an IO line is an acceptable second line option
-
psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - primarily driven by cesarean deliveries in low-risk births.2 While cesarean delivery may be the safest
option … reached over 30%.2 The increase
caused alarm because, while cesarean delivery is sometimes the safest option