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psnet.ahrq.gov/node/836941/psn-pdf
April 27, 2022 - of these standardized tools may support
more standardized, efficient, and evidence-based referral processes
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - errors in other settings has been found to be
effective, relevant, and educational about critical processes
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psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - exercised a prerogative that is important for all clinicians to have, as the ability to halt clinical processes
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psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
April 24, 2024 - Use of these standardized tools may support more standardized, efficient, and evidence-based referral processes
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psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
November 01, 2005 - Everyone here is coached that way, and we have processes in place to try to make that the case.
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - leukocytosis is present in only two thirds of cases and does not differentiate SEA from other infectious processes
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - Everyone here is coached that way, and we have processes in place to try to make that the case.
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psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
August 01, 2018 - How Does Health Care Simulation Affect Patient Care?
Joseph O. Lopreiato, MD, MPH | August 1, 2018
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Lopreiato JO. How Does Health Care Simulation Affect Patient Care?. PSNet [inter…
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - SPOTLIGHT CASE
Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations
Citation Text:
Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. PSNet [internet]. Rockville (MD): Agency for He…
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psnet.ahrq.gov/node/49824/psn-pdf
March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous
Delay
March 1, 2018
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
The Case
A 35-year-old woman with no prior cardiac history calle…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
October 01, 2010 - Spotlight Case July 2008
Spotlight Case October 2010
Dangerous Dialysis
*
*
Source and Credits
This presentation is based on the October 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…
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psnet.ahrq.gov/node/49866/psn-pdf
June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the
Operating Room
June 1, 2019
Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
The Case
A 43-year-old woman was admi…
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psnet.ahrq.gov/node/50697/psn-pdf
November 27, 2019 - Cardiac Arrest in a Woman with UTI: A Case of QT
Prolongation
November 27, 2019
Kulig CE, Ebong IA. Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation
The Case
A 36-year-old woman with a history of dep…
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psnet.ahrq.gov/node/33679/psn-pdf
January 01, 2009 - Disclosure of Medical Error
January 1, 2009
Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/disclosure-medical-error
Perspective
Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts
advocate that greater discl…
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psnet.ahrq.gov/node/49439/psn-pdf
March 01, 2004 - Lethal Cap
March 1, 2004
Schillinger D. Lethal Cap. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-cap
The Case
A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to
have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…
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psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
January 01, 2016 - Charcoal Lavage of the Lungs
Citation Text:
Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/node/49488/psn-pdf
August 21, 2005 - PCA Overdose
August 21, 2005
Doyle JD. PCA Overdose. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pca-overdose
The Case
A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo-
oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…
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psnet.ahrq.gov/node/49514/psn-pdf
July 01, 2006 - One ACE Too Many
July 1, 2006
Juurlink DN. One ACE Too Many. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/one-ace-too-many
The Case
A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure
presented to the emergency department (ED) with chest pain. An acut…
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psnet.ahrq.gov/node/49505/psn-pdf
March 01, 2006 - Collegiality vs. Competence
March 1, 2006
Sagin T. Collegiality vs. Competence. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/collegiality-vs-competence
The Case
A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective
repair of a 10-cm abdominal aortic aneurys…
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psnet.ahrq.gov/node/49845/psn-pdf
October 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug
Shortages
October 1, 2018
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
The Case
A 1-month-old preterm infant in the ne…