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digital.ahrq.gov/sites/default/files/docs/publication/r18hs018183-weiner-final-report-2013.pdf
January 01, 2013 - Medication Reconciliation Technology to Improve Quality of Transitional Care - Final Report
Grant Final Report
Grant ID: R18HS018183
Medication Reconciliation Technology to Improve
Quality of Transitional Care
Inclusive Project Dates: 09/30/09 – 07/31/13
Principal Investigator:
Michael Weiner
Team Member…
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - SPOTLIGHT CASE
The Wrong Shot: Error Disclosure
Citation Text:
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - The Consequences of Miscommunication Regarding a
Possible Artifact
June 30, 2021
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
Disclosure of Relevant Financial Relationships…
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psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
January 29, 2020 - Delayed Recognition of a Positive Blood Culture
Citation Text:
Doernberg S. Delayed Recognition of a Positive Blood Culture. 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/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
November 01, 2023 - Inadequate Preanesthetic Evaluation, Airway Trouble
Citation Text:
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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meps.ahrq.gov/data_files/publications/st482/stat482.shtml
November 01, 2015 - STATISTICAL BRIEF #482:
Specialist Need and Access among Adults with Multiple Chronic Conditions, U.S. Civilian Noninstitutionalized Population, 2012
Skip to main content
An official website of the Department of He…
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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line
Citation Text:
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue
Citation Text:
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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meps.ahrq.gov/data_files/publications/st409/stat409.shtml
June 01, 2013 - STATISTICAL BRIEF #409:
Heart Disease among Elderly Americans: Estimates for the U.S. Civilian Noninstitutionalized Population, 2010
Skip to main content
An official website of the Department of Health & Human Service…
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meps.ahrq.gov/data_files/publications/st440/stat440.shtml
June 01, 2014 - STATISTICAL BRIEF #440:
Expenditures for Treatment of Mental Health Disorders among Children, Ages 5-17, 2009-2011: Estimates for the U.S. Civilian Noninstitutionalized Population
Skip to main content
An official web…
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meps.ahrq.gov/data_files/publications/st393/stat393.shtml
November 01, 2012 - STATISTICAL BRIEF #393: Expenditures for Heart Disease among Adults Age 18 and Older: Estimates for the U.S. Civilian Noninstitutionalized Population, 2009
Skip to main content
An official website of the Department of He…
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meps.ahrq.gov/data_files/publications/st370/stat370.shtml
May 01, 2012 - STATISTICAL BRIEF #370:
Health and Insurance Status, Health Care Use, and Expenditures for Male Veterans, 2008: Estimates for the U.S. Civilian Noninstitutionalized Population
Skip to main content
An official website …
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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - Failure to Report
March 1, 2007
Spath P. Failure to Report. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/failure-report
Case Objectives
List common causes of medical errors.
Appreciate the magnitude of underreporting of adverse events.
List the common barriers to reporting adverse events and near misses…
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psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - Root Cause Analysis Gone Wrong
May 1, 2018
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
The Case
A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney
transplant. A suitabl…
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psnet.ahrq.gov/node/865778/psn-pdf
May 29, 2024 - Navigating Complications: The Unintended Journey of a
Guidewire During Dialysis Catheter Placement
May 29, 2024
Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis
Catheter Placement. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-complications-unint…
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - Empty Handoff
Citation Text:
Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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www.ahrq.gov/prevention/resources/depression/depsum1.html
April 01, 2013 - Screening for Depression in Adults
Summary of the Evidence
The summaries of the evidence briefly present evidence of effectiveness for preventive health services used in primary care clinical settings, including screening tests, counseling, and chemoprevention. They summarize the more detailed Systematic Evid…
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psnet.ahrq.gov/node/49570/psn-pdf
October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure?
October 1, 2008
Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
Case Objectives
Understand the complementary abilities of an electronic health record a…
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psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
January 01, 2021 - Spotlight
Spotlight
Two Cases of Retained Vaginal Packing:
When Writing an Order is Not Enough
Source and Credits
• This presentation is based on the April 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Verna Gibbs, MD
o AHRQ W…
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psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
October 19, 2022 - SPOTLIGHT CASE
Resuscitation Errors: A Shocking Problem
Citation Text:
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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…