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7461. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
      May 01, 2012 - Spotlight Case July 2008 Spotlight Case The Perils of Cross Coverage * * Source and Credits This presentation is based on the May 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …

7462. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49791/psn-pdf
      April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable April 1, 2017 Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable The Case An 84-year-old wo…

7463. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49727/psn-pdf
      March 01, 2015 - Critical Opportunity Lost March 1, 2015 Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/critical-opportunity-lost The Case A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She reported eating a heavy dinner the pre…

7464. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49463/psn-pdf
      October 14, 2004 - Moved Too Soon October 1, 2004 Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/moved-too-soon The Case A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours after arriving, while the patient was still groggy from anesthesia, a nurs…

7465. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60547/psn-pdf
      May 28, 2020 - The Role of the FDA in Ensuring Device Safety May 28, 2020 Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety Introduction The Food and Drug Administration (FDA) plays a critical role in ensuring the …

7466. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33860/psn-pdf
      June 01, 2018 - Safety Considerations in Building a Point-of-Care Ultrasound Program June 1, 2018 Moore C. Safety Considerations in Building a Point-of-Care Ultrasound Program. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program Perspective At the American Colle…

7467. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49832/psn-pdf
      June 01, 2018 - Febrile Neutropenia and an Almost Fatal Medication Error June 1, 2018 Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error The Case A 33-year-old woman with recently diagnosed acute …

7468. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33640/psn-pdf
      September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? September 1, 2006 Jha AK. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system…

7469. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.179_slideshow.ppt
      July 01, 2008 - Spotlight Case July 2008 Spotlight Case July 2008 Dependence vs. Pain Source and Credits This presentation is based on the July 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Adam J. Gordon, MD, MPH University of Pittsburgh School of M…

7470. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/612828/psn-pdf
      February 23, 2022 - Delayed Diagnosis of Kidney Transplant Complications February 23, 2022 Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications Objectives Recognition, early evaluation, and management of kidney …

7471. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49617/psn-pdf
      January 01, 2011 - Failure to Reevaluate December 1, 2010 Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/failure-reevaluate The Case A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community hospital developed methicillin-resistant staphylococc…

7472. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49471/psn-pdf
      December 01, 2004 - Carpe Diem (Seize the Day) December 1, 2004 Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day The Case A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic medical conditions including hypertension, h…

7473. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49487/psn-pdf
      August 21, 2005 - Surprise Wire August 21, 2005 Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/surprise-wire The Case A 39-year-old man with a history of liver disease presented to the emergency department (ED) with gastrointestinal bleeding and altered mental status. Due to his clinic…

7474. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49414/psn-pdf
      September 01, 2003 - Making Do September 1, 2003 Bradley LD. Making Do. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/making-do The Case A 56-year-old female with dysfunctional uterine bleeding and possible retained intrauterine device (IUD) was scheduled for elective hysteroscopy and dilation and curettage (D&C). Of note, sh…

7475. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33659/psn-pdf
      October 01, 2007 - Making Just Culture a Reality: One Organization's Approach October 1, 2007 Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach Perspective We've all been there...something goes wrong,…

7476. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.236_slideshow.ppt
      March 01, 2011 - Spotlight Case July 2008 Spotlight Case March 2011 Volume Too Low: In and Out Pediatric Patient Safety * * Source and Credits This presentation is based on the March 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Marlene Miller, MD, MSc…

7477. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49644/psn-pdf
      December 01, 2011 - Missing the Point—Eye Injury December 1, 2011 Sharma R, Brunette DD. Missing the Point—Eye Injury. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/missing-point-eye-injury The Case A 31-year-old woman presented to the emergency department (ED) after suffering multiple lacerations during an assault. The pati…

7478. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49850/psn-pdf
      January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia January 1, 2019 Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia The Case A 72-year-old woman with a history of severe peripheral vascular dis…

7479. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49755/psn-pdf
      February 01, 2016 - Good Night's Sleep Gone Wrong February 1, 2016 Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong The Case A 64-year-old woman came to the emergency department complaining of cough and shortness of breath, along with an…

7480. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49805/psn-pdf
      September 01, 2017 - The Forgotten Radiographic Read September 1, 2017 Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read The Case A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for management of inferior…