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psnet.ahrq.gov/node/49812/psn-pdf
November 01, 2017 - Specimen Almost Lost
November 1, 2017
Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/specimen-almost-lost
The Case
A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen.
She was admitted to the medicine service for further evalu…
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
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psnet.ahrq.gov/node/850362/psn-pdf
June 14, 2023 - Home Medications Contribute to a Unique Opportunity for
Error on Discharge from the Hospital
June 14, 2023
Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from
the Hospital. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…
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psnet.ahrq.gov/node/49628/psn-pdf
June 01, 2011 - Routine Goes Awry
June 1, 2011
Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/routine-goes-awry
The Case
A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and
scheduled for a tonsillectomy and adenoidectomy. She was in ot…
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www.ahrq.gov/hai/pfp/haccost2017-discuss.html
November 01, 2017 - Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions
Discussion
Previous Page Next Page
Table of Contents
Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions
Discussio…
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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - Right Electrocardiogram, Wrong Patient
March 25, 2020
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
The Cases
Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…
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psnet.ahrq.gov/node/49860/psn-pdf
April 01, 2019 - Hip Fractures in Older Patients: the Case for Geriatrics
Comanagement
April 1, 2019
Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
The Case
An 82-year-old man …
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www.ahrq.gov/gam/summaries/domain-definitions/index.html
July 01, 2018 - NQMC Measure Domain Definitions
Health Care Delivery Measure Domains
Measures of care delivered to individuals and populations defined by their relationship to clinicians, clinical delivery teams, delivery organizations, or health insurance plans. Denominators for these measures are defined by some form of af…
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psnet.ahrq.gov/node/73412/psn-pdf
August 01, 2022 - “Behavioral Health Vital Signs” Initiative Increases Patient
Education and Disclosure about Interpersonal Violence
(IPV)
June 30, 2021
https://psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-
disclosure
Summary
The Behavioral Health Vital Signs (BHVS) screener i…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.149_slideshow.ppt
May 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case May 2007
Antiseizure Medication Disorder
Source and Credits
This presentation is based on the May 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Brian K. Alldredge, Pharm…
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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…
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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…
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psnet.ahrq.gov/node/60653/psn-pdf
April 25, 2020 - Health Care Delivery and Pharmacists During the COVID-
19 Pandemic
June 29, 2020
Dopp AL, Fitall E, Hall KK, et al. Health Care Delivery and Pharmacists During the COVID-19 Pandemic.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
Medication…
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psnet.ahrq.gov/node/49814/psn-pdf
December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation
Mishap
December 1, 2017
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
The Case
A 63-year-old man with a history of coronary…
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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…
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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 …
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psnet.ahrq.gov/node/49438/psn-pdf
March 05, 2004 - OR Peeping
March 1, 2004
Mackenzie CF. OR Peeping. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/or-peeping
The Case
A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete
spontaneous abortion (miscarriage).
At this community hospital, a new operating room (OR) su…
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www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part2-diabetes.html
May 01, 2018 - Chartbook for Hispanic Health Care
Part 2: Trends in Priorities of the Heckler Report—Care for Diabetes
Previous Page Next Page
Table of Contents
Chartbook for Hispanic Health Care
Acknowledgments
Health Care For Hispanics
National Quality Strategy Priorities: Patient Safety
National Quality…
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www.ahrq.gov/research/findings/nhqrdr/chartbooks/access/elements4.html
June 01, 2018 - Chartbook on Access to Health Care
Elements of Access to Health Care: Workforce Capacity
Previous Page Next Page
Table of Contents
Chartbook on Access to Health Care
Acknowledgments
Access to Health Care
Elements of Access to Health Care
Elements of Access to Health Care: Services
Elements…
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psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me
May 01, 2019 - Electrocardiogram Results: ***READ ME***
Citation Text:
Alpert JS. Electrocardiogram Results: ***READ ME***. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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