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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
    April 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case April 2008 Antibiotics for URI/Sinusitis: A Simple Decision Gone Bad Source and Credits This presentation is based on the April 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Sumant Ranji, MD,…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49745/psn-pdf
    October 01, 2015 - Amphotericin Toxicity October 1, 2015 Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/amphotericin-toxicity The Case A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral posaconazole for residual fungal disease. She present…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49814/psn-pdf
    December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation Mishap December 1, 2017 Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap The Case A 63-year-old man with a history of coronary…
  4. psnet.ahrq.gov/web-mm/discharged-blindly
    October 26, 2022 - Discharged Blindly Citation Text: Iezzoni LI. Discharged Blindly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33640/psn-pdf
    September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? September 1, 2006 Jha AK. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49623/psn-pdf
    March 01, 2011 - Are We Pushing Graduate Nurses Too Fast? March 1, 2011 Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast The Case A middle-aged man was admitted to the surgical intensive care unit (SICU) following a complex surgical…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49389/psn-pdf
    February 01, 2003 - Procedural Mishap: Learning Curve? February 1, 2003 Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve The Case A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had undesired fert…
  8. psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
    March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety Sara J. Singer, MBA, PhD | September 1, 2013  View more articles from the same authors. Citation Text: Singer SJ. What We've Learned About Leveraging Leadership a…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49515/psn-pdf
    July 01, 2006 - Over Not So Easy July 1, 2006 Cucina R. Over Not So Easy. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/over-not-so-easy The Case A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On admission, she reported allergies to a number of medications as well as a …
  10. psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
    December 15, 2024 - Medication Errors and Adverse Drug Events Citation Text: Medication Errors and Adverse Drug Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…
  11. psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me
    May 01, 2019 - Electrocardiogram Results: ***READ ME*** Citation Text: Alpert JS. Electrocardiogram Results: ***READ ME***. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…
  12. psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma
    February 26, 2025 - In Conversation With… Lorri Zipperer, MA November 1, 2015  Citation Text: In Conversation With… Lorri Zipperer, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867429/psn-pdf
    December 18, 2024 - Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis December 18, 2024 Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. 2024. https://psnet.ahrq.gov/w…
  14. psnet.ahrq.gov/Webmm
    May 01, 2021 - WebM&M Cases & Commentaries WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by…
  15. psnet.ahrq.gov/webmm
    May 01, 2021 - WebM&M Cases & Commentaries WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by…
  16. psnet.ahrq.gov/perspective/conversation-chris-cebollero-bs-ccemt-p
    May 26, 2021 - In Conversation With... Chris Cebollero, BS, CCEMT-P May 26, 2021  Also Read the Essay Citation Text: In Conversation With.. Chris Cebollero, BS, CCEMT-P. PSNet [internet]. 2021.In Conversation With... Chris Cebollero, BS, CCEMT-P. PSNet [internet]. Rockville (MD)…
  17. psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
    September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? Ashish K. Jha, MD, MPH | September 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Jha AK. What Can the Rest of the Heal…
  18. psnet.ahrq.gov/perspective/what-makes-good-checklist
    October 01, 2010 - What Makes a Good Checklist Anne Collins McLaughlin, PhD | October 1, 2010  Also Read a Conversation View more articles from the same authors. Citation Text: McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
  19. psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
    October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD October 1, 2010  Also Read an Essay Citation Text: In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010.In Conversation with...Peter J. Pronovost, MD, PhD. PSNet [internet]. Rockville (MD): Ag…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866579/psn-pdf
    August 28, 2024 - Infection After Carpal Tunnel Surgery August 28, 2024 Szabo RM. Infection After Carpal Tunnel Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery The Case A woman presented for surgery on her right wrist as a treatment for carpal tunnel syndrome. There were no repo…

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