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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/50949/psn-pdf
February 26, 2020 - Pre-analytical pitfalls: Missing and mislabeled specimens
February 26, 2020
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
The Case
Case #1:
A 56-year-old man was admitted to…
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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/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.
Copy Citation
…
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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/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities
Citation Text:
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…
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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.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - The Inside of a Time Out
Citation Text:
Feldman DL. The Inside of a Time Out. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
January 01, 2024 - Spotlight
Spotlight
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
1
Source and Credits
This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Garth Utter, MD, MSc, FACS…
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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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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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psnet.ahrq.gov/node/61083/psn-pdf
October 28, 2020 - Unfortunately, when you do nursing home research, turnover is
just part of the organization.
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - fraction of that—one fiftieth or one hundredth of that when you look at the budget of AHRQ and other organizations
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psnet.ahrq.gov/node/857059/psn-pdf
November 29, 2023 - The Risks of a Malpositioned Gastrostomy Tube and Poor
Communication
November 29, 2023
Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet].
2023.
https://psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
Disclosure of Relevant Financial …
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psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
March 01, 2011 - What Have We Learned About Safe Inpatient Handovers?
Sunil Kripalani, MD, MSc | March 1, 2011
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Kripalani S. What Have We Learned About Safe Inpatient Handovers?. PSNet [internet]. …
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - Some brands use Jackson sizing and others use International Sizing Organization (ISO) standards.
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - December 14, 2022
Factors causing variation in World Health Organization surgical
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psnet.ahrq.gov/node/33728/psn-pdf
May 01, 2012 - And, we found voluntary reporting picked up no adverse events at that organization.
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psnet.ahrq.gov/node/49666/psn-pdf
October 01, 2012 - CA-MRSA Skin Infections: An Ounce of Prevention is
Worth a Pound of Cure
October 1, 2012
Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet].
2012.
https://psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
Case Objectives
Identify risk f…
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - Right Patient, Wrong Sample
Citation Text:
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…