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psnet.ahrq.gov/node/49612/psn-pdf
November 01, 2010 - Treatment Challenges After Discharge
November 1, 2010
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
Case Objectives
Understand types and frequencies of adverse events occurring between patient discharge from the
hospital …
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psnet.ahrq.gov/node/72618/psn-pdf
December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral
Changes Towards Medical Decisions that Improve Care
Value and Quality of Care
December 23, 2020
https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-
medical-decisions
Summary
Nudges are a change in the way choices ar…
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psnet.ahrq.gov/web-mm/departure-central-line-ritual
October 13, 2018 - Departure From Central Line Ritual
Citation Text:
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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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/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…
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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…
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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.407_slideshow.ppt
May 01, 2017 - PowerPoint Presentation
Spotlight
Diagnostic Delay in the Emergency Department
1
Source and Credits
This presentation is based on the May 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…
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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…
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - Add-on Case and the Missing Checklist
Citation Text:
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
February 26, 2025 - In Conversation with...Diane Rydrych, MA
June 1, 2007
Citation Text:
In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007.In Conversation with...Diane Rydrych, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department…
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psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - Harm From Alarm Fatigue
December 1, 2015
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/harm-alarm-fatigue
Case Objectives
Define alarm fatigue and describe potential errors that can occur due to alarm fatigue.
Identify federal and national agencies focusing on …
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psnet.ahrq.gov/web-mm/wrong-channel
February 01, 2003 - The Wrong Channel
Citation Text:
Gosbee JW. The Wrong Channel
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/web-mm/too-much-too-fast
June 14, 2019 - Too Much, Too Fast
Citation Text:
Tuot D. Too Much, Too Fast. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - Patient Safety Indicators
Citation Text:
Tokareva I, Romano P. Patient Safety Indicators.. 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/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis
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psnet.ahrq.gov/perspective/emergence-application-based-healthcare
August 05, 2022 - We can provide patients with recommended apps that help them learn more about their health condition,
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psnet.ahrq.gov/perspective/conversation-francoise-marvel-md
August 05, 2022 - We can provide patients with recommended apps that help them learn more about their health condition,
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Medication Mix-Up: From Bad to Worse
Citation Text:
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
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