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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - "Superficial" Report Leads to "Deep" Problem
Citation Text:
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - Pocket Syringe Swap
May 1, 2011
Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/pocket-syringe-swap
The Case
A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for
postoperative pain management. Surgery proceeded uneventfully under…
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psnet.ahrq.gov/perspective/patient-safety-home-dialysis
April 28, 2021 - Patient Safety in Home Dialysis
April 28, 2021
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx
Spotlight
A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion
Source and Credits
• This presentation is based on the July 2023 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia
Citation Text:
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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…
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psnet.ahrq.gov/web-mm/its-all-syringe
February 01, 2013 - It's All in the Syringe
Citation Text:
Weingart SN. It's All in the Syringe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - Primary Workaround, Secondary Complication
Citation Text:
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar B…
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psnet.ahrq.gov/node/49706/psn-pdf
January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication
Access Issue
April 1, 2014
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
The Case
A 24-year-old wom…
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psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
March 29, 2023 - Walking Out of a Hospital After Attempted Suicide
Citation Text:
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
Googl…
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psnet.ahrq.gov/node/49872/psn-pdf
August 08, 2019 - Spinal Epidural Abscess
August 8, 2019
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess
The Case
A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a
few days of progressive low back pain. She…
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psnet.ahrq.gov/node/49833/psn-pdf
June 01, 2018 - Perils in Diagnosing a Stroke
June 1, 2018
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
The Case
A 75-year-old man with a history of hypertension, diabetes, chronic back pain, and opioid use disorder was
brought to the emergency depart…
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - July Syndrome
June 1, 2016
Young JQ. July Syndrome. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/july-syndrome
The Case
A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower
lobe lung cancer. The attending surgeon saw the patient along with his fellow,…
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psnet.ahrq.gov/node/49481/psn-pdf
May 01, 2005 - Discharge Against Medical Advice
May 1, 2005
Hwang SW. Discharge Against Medical Advice. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/discharge-against-medical-advice
The Case
A 50-year-old man with a history of alcohol abuse and alcohol-induced dementia was admitted to the
medical service with mild alco…
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - Abnormal Volunteer Results
Citation Text:
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - Low on the Totem Pole
December 1, 2005
Wachter R. Low on the Totem Pole. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/low-totem-pole
Case Objectives
Understand the concept of authority gradient
List steps that can be taken to increase communication across an authority gradient
Consider the current cultu…
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psnet.ahrq.gov/node/50929/psn-pdf
February 26, 2020 - Discharged with IV antibiotics: When issues arise, who
manages the complications?
February 26, 2020
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the
complications? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-…
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psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
June 01, 2015 - Physicians should be very cautious about prescribing glucocorticoids for periods longer than several
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psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
September 25, 2019 - and Maternal Health
October 6, 2021
Assessment of potentially inappropriate prescribing
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - March 24, 2021
WebM&M Cases
Multiple Levels Involved in Prescribing
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - Safety and Adherence to Self-Administered Medications
July 1, 2011
Decreasing prescribing