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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49632/psn-pdf
    July 01, 2011 - A Seasonal Care Transition Failure July 1, 2011 Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure The Case A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine resident—for routine follow-up…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49576/psn-pdf
    January 01, 2009 - To Transfer or Not to Transfer January 1, 2009 Pines JM. To Transfer or Not to Transfer. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/transfer-or-not-transfer Case Objectives Explore the benefits of the continuity of hospital care. Understand the rules and regulations behind triage and hospital choice de…

  3. Too Many Cooks Spotlight Pdf (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
    January 01, 2020 - Spotlight Too Many Cooks in the Kitchen Source and Credits • This presentation is based on the August 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: Richard P. Dutton, MD, MBA o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72693/psn-pdf
    January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…

  5. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
    January 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case January 2008 How Do Providers Recover from Errors? Source and Credits This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Colin P. West, MD, PhD, Mayo Clini…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33845/psn-pdf
    November 01, 2017 - In Conversation With… Wanda Pratt, PhD November 1, 2017 In Conversation With… Wanda Pratt, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd Editor's note: Wanda Pratt is a Professor in the Information School with an adjunct appointment in the Division of Biomedical and …

  7. Procedural Mishap: Learning Curve? | PSNet

    psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
    April 28, 2021 - Procedural Mishap: Learning Curve? Citation Text: Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

  8. Spotlight Case July 2008 (ppt file)

    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…

  9. Medication Reconciliation Pitfalls | PSNet

    psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
    May 01, 2006 - Medication Reconciliation Pitfalls Citation Text: Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73902/psn-pdf
    September 29, 2021 - Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome September 29, 2021 Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet]. 2021. https://psnet.ahrq.go…

  11. In Conversation With…David C. Classen, MD, MS | PSNet

    psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
    May 01, 2012 - And, we found voluntary reporting picked up no adverse events at that organization. … States hospitals.( 1 ) In response to these disturbing data, accreditation bodies, payers, nonprofit organizations

  12. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
    May 01, 2012 - States hospitals.( 1 ) In response to these disturbing data, accreditation bodies, payers, nonprofit organizations … And, we found voluntary reporting picked up no adverse events at that organization.

  13. Missing Trauma | PSNet

    psnet.ahrq.gov/web-mm/missing-trauma
    March 03, 2011 - Missing Trauma Citation Text: Jurkovich GJ. Missing Trauma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  14. Are We Pushing Graduate Nurses Too Fast? | PSNet

    psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
    November 16, 2022 - Are We Pushing Graduate Nurses Too Fast? Citation Text: Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  15. Bloody BP Cuff | PSNet

    psnet.ahrq.gov/web-mm/bloody-bp-cuff
    June 21, 2016 - Bloody BP Cuff Citation Text: Madan AK. Bloody BP Cuff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  16. Good Night's Sleep Gone Wrong | PSNet

    psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
    September 01, 2015 - Good Night's Sleep Gone Wrong Citation Text: Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML…

  17. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
    August 01, 2014 - PowerPoint Presentation Spotlight Pitfalls in Diagnosing Necrotizing Fasciitis This presentation is based on the July/August 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Terence Goh, MBBS, Department of Plastic Surgery, Singapore General Hos…

  18. Delayed Diagnosis of Kidney Transplant Complications | PSNet

    psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
    January 29, 2020 - Delayed Diagnosis of Kidney Transplant Complications Citation Text: Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Goo…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49794/psn-pdf
    May 01, 2017 - Communication Error in a Closed ICU May 1, 2017 Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/communication-error-closed-icu The Case A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney transplant), co…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73229/psn-pdf
    May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities May 26, 2021 Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…
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