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psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - Medication Mix-Up Leads to Patient Death
November 30, 2023
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
The Case
An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
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psnet.ahrq.gov/node/49402/psn-pdf
June 01, 2003 - Inappropriate Antibiotic Use
June 1, 2003
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
The Case
A 41-year-old woman presented to the hospital with acute renal failure, which came to be diagnosed as a
first presentation of s…
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psnet.ahrq.gov/node/49588/psn-pdf
August 01, 2009 - Nurse Staffing Ratios: The Crucible of Money, Policy,
Research, and Patient Care
August 1, 2009
Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
Case…
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - SPOTLIGHT CASE
Moving Pains
Citation Text:
Schell H, Wachter R. Moving Pains. 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/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.
Citation Text:
Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
February 23, 2022 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement
Citation Text:
Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Failure to Rescue the Mother
Citation Text:
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/FExZhpEq2337V-hwkaPQ8y
May 01, 2002 - Screening for Depression - Recommendations and Rationale
121
Summary of
Recommendations
• The U.S. Preventive Services Task Force
(USPSTF) recommends screening adults for
depression in clinical practices that have systems
in place to assure accurate diagnosis, effective
treatment, and follow-up. B recommendation.
…
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psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - SPOTLIGHT CASE
Watch the Warfarin!
Citation Text:
Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/check-twice-transport-once
March 15, 2023 - Check Twice, Transport Once
Citation Text:
DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - SPOTLIGHT CASE
The ECG Is Not Normal
Citation Text:
Zuger A. The ECG Is Not Normal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - SPOTLIGHT CASE
Right? Left? Neither!
Citation Text:
Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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effectivehealthcare.ahrq.gov/sites/default/files/hawley-presentation.pdf
October 08, 2025 - Hawley-notes-151016 copy - Teresa
This idea of focusing on patient-centered medical care has been one that’s come to
the forefront in the last decade and we’ve heard a lot about that.
1
…
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs015377-schadow-final-report-2008.pdf
January 01, 2008 - Value of New Drug Knowledge for e-Prescribing
Grant Final Report
Grant ID: R01HS15377
Value of New Drug Knowledge for e-Prescribing
Inclusive Dates: 09/8/04 - 08/31/08
Principal Investigator:
Gunther Schadow
Team Members:
CJ Fleck
Mahesh Nalkande
Akshay Sangawar
Chris Rosenth…
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psnet.ahrq.gov/web-mm/undetected-foreign-object
April 24, 2018 - Undetected Foreign Object
Citation Text:
Cima RR. Undetected Foreign Object. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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hcup-us.ahrq.gov/reports/statbriefs/sb23.pdf
January 01, 2007 - HCUP Statistical Brief #122: Bariatric Surgery Utilization and Outcomes in 1998 and 2004
HEALTHCARE COST AND
UTILIZATION PROJECT
Agen
Res
January 2007
From
numbe
increa
to 121
Across
fastes
surger
adults
fold in
surger
16,000
The na
assoc
declin
percen
in 200
died in
which
perfor
…
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psnet.ahrq.gov/node/846769/psn-pdf
March 29, 2023 - Missed Diagnosis of Addison’s Disease in Adolescent
Presenting with Fatigue.
March 29, 2023
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
The C…
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hcup-us.ahrq.gov/reports/ataglance/HCUPCDiffHosp2011-2015Rpt081618.pdf
August 18, 2018 - Recommended Citation: Barrett ML, Owens PL. Clostridium Difficile Hospitalizations,
2011-2015. ONLINE. August 18, 2018. U.S. Agency for Healthcare Research and
Quality. Available: www.hcup-us.ahrq.gov/reports.jsp.
CLOSTRIDIUM DIFFICILE HOSPITALIZATIONS
2011-2015
HCUP (08/16/18) CDI Hospitalizations 2…
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hcup-us.ahrq.gov/reports/ataglance/HCUPanalysisCdiff.pdf
April 12, 2021 - HCUPanalysisCdiff2019
Adult, Nonmaternal Inpatient Stays Related to Clostridioides difficile:
National Trends, 2011-2016 and 2019
April 12, 2021
Recommended Citation: Adult, Nonmaternal Inpatient Stays Related to Clostridioides difficile: N…