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psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
June 01, 2016 - A Seasonal Care Transition Failure
Citation Text:
Young JQ. A Seasonal Care Transition Failure. 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/web-mm/wrongful-resuscitation
October 12, 2012 - The Wrongful Resuscitation
Citation Text:
Teno JM. The Wrongful Resuscitation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
March 25, 2020 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules
Citation Text:
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Some brands use Jackson sizing and others use
International Sizing Organization (ISO) standards.
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psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - September 11, 2024
Did the organization of primary care practices during the COVID-19
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - October 4, 2023
Factors causing variation in World Health Organization surgical safety
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psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
July 31, 2023 - Procedure Complications – Who is Responsible for Follow up?
Citation Text:
Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - Mother's Milk, but Whose Mother?
Citation Text:
Dougherty D. Mother's Milk, but Whose Mother?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - SPOTLIGHT CASE
How Do Providers Recover From Errors?
Citation Text:
West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue
Citation Text:
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
November 01, 2023 - Inadequate Preanesthetic Evaluation, Airway Trouble
Citation Text:
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/more-treatment-better-care
August 11, 2021 - More Treatment—Better Care?
Citation Text:
Redberg R. More Treatment—Better Care?. 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/49552/psn-pdf
January 01, 2008 - How Do Providers Recover From Errors?
January 1, 2008
West CP. How Do Providers Recover From Errors? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
Case Objectives
Describe the provider-specific prevalence of medical errors.
Appreciate the impact of medical errors on care pr…
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psnet.ahrq.gov/node/49798/psn-pdf
July 01, 2017 - Pseudo-obstruction But a Real Perforation
July 1, 2017
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
Case Objectives
Recognize acute colonic pseudo-obstruction and implement a medical management plan.
Ide…
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psnet.ahrq.gov/node/49799/psn-pdf
July 01, 2017 - Delayed Recognition of a Positive Blood Culture
July 1, 2017
Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
The Case
A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/node/49567/psn-pdf
September 01, 2008 - Empiric Steroids: the Good, the Bad, and the Ugly
September 1, 2008
Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
Case Objectives
Describe appropriate indications for use of steroids.
Appreciate contraindicati…
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - SPOTLIGHT CASE
The Hazards of Distraction: Ticking All the EHR Boxes
Citation Text:
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Communication Error in a Closed ICU
Citation Text:
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33806/psn-pdf
April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of
Pediatrics a…