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psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
August 02, 2015 - most significant mistake and their response to it.( 13 ) Mistakes included errors in diagnosis (33%), prescribing
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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
September 27, 2023 - SPOTLIGHT CASE
Missed Opportunities for Suicide Risk Assessment
Citation Text:
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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For…
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psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - October 19, 2022
Telemedicine vs telephone consultations and medication prescribing errors
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing
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psnet.ahrq.gov/web-mm/dual-therapy-debacle
February 01, 2007 - Dual Therapy Debacle
Citation Text:
Kayser SR. Dual Therapy Debacle. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/node/49442/psn-pdf
May 01, 2004 - Missed TB
May 1, 2004
FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/missed-tb
The Case
A 38-year-old white female with no past medical history presented to the hospital with fevers, respiratory
failure, and bilateral pulmonary infiltrates. She was treated empirically w…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
December 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case December 2004
Discharge Fumbles
Source and Credits
This presentation is based on the Dec. 2004
AHRQ WebM&M Spotlight Case in Hospital Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Alan Forster, M…
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psnet.ahrq.gov/node/49595/psn-pdf
December 01, 2009 - "Superficial" Report Leads to "Deep" Problem
December 1, 2009
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
The Case
A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…
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psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - Lethal Cap
Citation Text:
Schillinger D. Lethal Cap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Do…
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - Strategies to Improve Organizational Health Literacy.
May 31, 2023
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
Background
Health literacy is important at both the personal …
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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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psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - Infection After Carpal Tunnel Surgery
Citation Text:
Szabo RM. Infection After Carpal Tunnel Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNo…
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - Challenges include but are not limited to 16
Decreased access to clinical decision support tools for prescribing
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - November 16, 2022
Opioid prescribing for acute pain management in children and adolescents
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - February 23, 2011
Reducing prescribing errors in hospitalized children on the ketogenic
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psnet.ahrq.gov/web-mm/volume-too-low-and-out
July 01, 2017 - We know that errors in prescribing, dispensing, and administering medications represent a substantial
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psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - August 26, 2020
Prescribing patterns of heart failure-exacerbating medications following
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - November 10, 2015
Unrealized potential and residual consequences of electronic prescribing
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - October 31, 2011
Opioid prescribing for acute pain management in children and adolescents
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - The care these doctor/parents provided included otoscopy, chest auscultation, and antibiotic prescribing