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psnet.ahrq.gov/node/49411/psn-pdf
July 01, 2003 - Code Status Confusion
July 1, 2003
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/code-status-confusion
Case Objectives
Appreciate challenges of determining goals of care in hospitalized patients
Understand patients’ common misconceptions about CPR
List typical mist…
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psnet.ahrq.gov/node/857260/psn-pdf
November 30, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP
(Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
November 30, 2023
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2
Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/when…
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psnet.ahrq.gov/node/49545/psn-pdf
September 01, 2007 - Coming Undone: Failure of Closure Device
September 1, 2007
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
The Case
A 65-year-old man underwent coronary angiography because of atypical exertional chest…
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psnet.ahrq.gov/node/49789/psn-pdf
April 01, 2017 - Engaging Seriously Ill Older Patients in Advance Care
Planning
April 1, 2017
Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
Case Objectives
Define advance care planning an…
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psnet.ahrq.gov/node/49440/psn-pdf
March 01, 2004 - Autopsy Revelation
March 1, 2004
Shojania KG. Autopsy Revelation. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/autopsy-revelation
The Case
A 45-year-old male with development delay presented to the emergency department with acute abdominal
pain. His mother, who was his main caregiver, accompanied him. Th…
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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…
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psnet.ahrq.gov/node/49594/psn-pdf
December 01, 2009 - Standard Deviations
December 1, 2009
Sabin JE. Standard Deviations. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/standard-deviations
Case Objectives
Understand the safety risks associated with patients being discharged against medical advice
(AMA).
Recognize safety risks associated with being part of a …
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - Around the Block
Citation Text:
Minichiello T. Around the Block. 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 Endnote tagged PubMedId RIS …
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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…
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psnet.ahrq.gov/node/49787/psn-pdf
March 01, 2017 - Diagnosing a Missed Diagnosis
March 1, 2017
Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
The Case
A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and
disorientation. She was taking mod…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfer Troubles
1
2
Source and Credits
This presentation is based on the June 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…
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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…
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psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - A Mistaken Dose of Naloxone
Citation Text:
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
-
psnet.ahrq.gov/node/33605/psn-pdf
March 12, 2021 - Medication Administration Errors
March 12, 2021
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/medication-administration-errors
Updated in March 2021. Originally published in January 2018 by researchers at the University of California,
San Fra…
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psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
August 05, 2009 - Discharge Instructions in the PACU: Who Remembers?
Citation Text:
Engel KG. Discharge Instructions in the PACU: Who Remembers?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar B…
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psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure
to Rescue after Limited Response to Nursing Concerns.
July 10, 2024
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response
to Nursing Concerns. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hemorrhagic-sh…
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.
Citation Text:
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - SPOTLIGHT CASE
How Do Providers Recover From Errors?
Citation Text:
West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar Bi…
-
psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - SPOTLIGHT CASE
Engaging Seriously Ill Older Patients in Advance Care Planning
Citation Text:
Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. …
-
psnet.ahrq.gov/web-mm/autopsy-revelation
December 01, 2007 - Autopsy Revelation
Citation Text:
Shojania KG. Autopsy Revelation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…