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  1. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.176_slideshow.ppt
    May 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case May 2008 Diagnosing HIV: It Doesn’t Take a Brain Surgeon Source and Credits This presentation is based on the May 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Roger Chou, MD, Oregon Health &…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49677/psn-pdf
    February 01, 2013 - CVC Placement: Speak Now or Do Not Use the Line February 1, 2013 Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line The Case A 48-year-old woman with a history of hypertension, psychiatric illness, and a…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49627/psn-pdf
    June 01, 2011 - The ECG Is Not Normal June 1, 2011 Zuger A. The ECG Is Not Normal. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/ecg-not-normal Case Objectives State how frequently physicians care for family or relatives. Describe the risks associated with caring for family members or relatives. Appreciate some of the s…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865984/psn-pdf
    May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. May 29, 2024 Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D- dimer. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49664/psn-pdf
    January 01, 2013 - Empty Handoff September 1, 2012 Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/empty-handoff The Case A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a leg wound. The patient's medical history included chronic…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33743/psn-pdf
    December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit December 1, 2012 Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit. PSNet [internet]. 2012. https://psnet.ahrq.gov…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49621/psn-pdf
    March 01, 2011 - Volume Too Low: In and Out March 1, 2011 Miller MR. Volume Too Low: In and Out . PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/volume-too-low-and-out Case Objectives Appreciate that because of multiple factors, children are at high risk for medical errors. Describe the importance of weight-based dosing of…

  8. Preventing PICC Complications: Whose Line Is It? | PSNet

    psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
    October 01, 2017 - Preventing PICC Complications: Whose Line Is It? Citation Text: Moureau N. Preventing PICC Complications: Whose Line Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibT…

  9. Discharge Against Medical Advice | PSNet

    psnet.ahrq.gov/web-mm/discharge-against-medical-advice
    July 01, 2017 - Discharge Against Medical Advice Citation Text: Hwang SW. Discharge Against Medical Advice. 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 E…

  10. Sick and Pregnant | PSNet

    psnet.ahrq.gov/web-mm/sick-and-pregnant
    August 25, 2021 - Sick and Pregnant Citation Text: El-Ibiary S. Sick and Pregnant. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  11. Danger in Disruption | PSNet

    psnet.ahrq.gov/web-mm/danger-disruption
    July 29, 2020 - Danger in Disruption Citation Text: Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…

  12. Shortcuts to Acetaminophen-induced Liver Failure | PSNet

    psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
    July 01, 2017 - Shortcuts to Acetaminophen-induced Liver Failure Citation Text: Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google S…

  13. A Seasonal Care Transition Failure | PSNet

    psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
    June 01, 2016 - A Seasonal Care Transition Failure Citation Text: Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33596/psn-pdf
    June 01, 2025 - Failure to Rescue January 29, 2025 Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/failure-rescue Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet primers are regularly reviewed and updated to ensure that they reflect cur…

  15. Returning Home Safely | PSNet

    psnet.ahrq.gov/web-mm/returning-home-safely
    December 22, 2018 - Returning Home Safely Citation Text: Toles M. Returning Home Safely. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49470/psn-pdf
    December 01, 2004 - Discharge Fumbles December 1, 2004 Forster AJ. Discharge Fumbles. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/discharge-fumbles Case Objectives List the types of adverse events that occur at discharge Identify the characteristics that identify patients at high risk for errors at discharge Understand th…

  17. After-Visit Confusion | PSNet

    psnet.ahrq.gov/web-mm/after-visit-confusion
    August 21, 2007 - After-Visit Confusion Citation Text: Ventres W. After-Visit Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…

  18. Webmm Spotlight Suicide Risk Assessment (pdf file)

    psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
    January 01, 2019 - Spotlight Missed Opportunities for Suicide Risk Assessment Source and Credits • This presentation is based on the November 2019 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Glen Xiong, MD & Debra Kahn, MD ○ Editors in Chief, AHRQ We…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850675/psn-pdf
    June 14, 2023 - Patient and Family Roles in Safety June 14, 2023 Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety Moving From Engagement to Partnership Involving patients and families in healthcare decisions about patient c…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836839/psn-pdf
    March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare Staff March 31, 2022 Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff Introduction The…
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