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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
    January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866992/psn-pdf
    May 29, 2024 - Harm Reduction Strategies to Improve Safety for People Who Use Substances October 30, 2024 Salisbury-Afshar E, Gale B, Mossburg S. Harm Reduction Strategies to Improve Safety for People Who Use Substances . PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-w…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865455/psn-pdf
    March 27, 2024 - Communication During Transitions of Care March 27, 2024 Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/communication-during-transitions-care Introduction Inaccurate or untimely communication and ineffective teamwork in healthca…
  4. psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
    April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens Citation Text: Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33680/psn-pdf
    March 22, 2009 - In Conversation with...Dean Schillinger, MD March 22, 2009 In Conversation with..Dean Schillinger, MD. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md Editor's note: Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco, Directo…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49648/psn-pdf
    March 01, 2012 - Postdischarge Follow-Up Phone Call March 1, 2012 Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call Case Objectives Understand why preventing readmissions through postdischarge phone calls is important. Describe evidence su…
  7. psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
    October 30, 2024 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission Save Save to your library Print Download PDF Share Facebook Twitter Linkedin C…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33740/psn-pdf
    November 01, 2012 - In Conversation With… Abraham Verghese, MD November 1, 2012 In Conversation With… Abraham Verghese, MD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-abraham-verghese-md Editor's note: Abraham Verghese, MD, is Professor for the Theory and Practice of Medicine at the Stanford University S…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863308/psn-pdf
    February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy February 28, 2024 Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy The Case A…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49624/psn-pdf
    May 01, 2011 - Duty to Disclose Someone Else's Error? May 1, 2011 Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error Case Objectives State the rationale for disclosing medical errors. Describe key principles in effective error disclosure. …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49388/psn-pdf
    February 01, 2003 - Unexplained Apnea Under Anesthesia February 1, 2003 Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia Case Objectives Clinical Objectives List the causes of prolonged apnea in the operating room Describe the steps in management …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49758/psn-pdf
    April 01, 2016 - Dropping to New Lows April 1, 2016 Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/dropping-new-lows Case Objectives State how to manage diabetes medications when patients are admitted to the hospital Describe a guideline-recommended insulin regimen for a hospitaliz…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33720/psn-pdf
    November 01, 2011 - In Conversation With… Eduardo Salas, PhD November 1, 2011 In Conversation With… Eduardo Salas, PhD . PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd Editor's note: Eduardo Salas, PhD, is a University Trustee Chair and Pegasus Professor of Psychology at the University of Ce…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33843/psn-pdf
    October 01, 2017 - In Conversation With… Jeffrey Starke, MD October 1, 2017 In Conversation With… Jeffrey Starke, MD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-jeffrey-starke-md Editor's note: Dr. Starke is Professor of Pediatrics–Infectious Disease at Baylor College of Medicine and served as Infection…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49861/psn-pdf
    May 01, 2019 - Updates in the Management of High-Risk Pulmonary Embolism May 1, 2019 Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism Case Objectives Review common risk factors, typical present…
  16. psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
    February 26, 2025 - In Conversation With… Shantanu Agrawal, MD, MPhil September 1, 2019  Citation Text: In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Co…
  17. psnet.ahrq.gov/Information/Panel
    January 01, 2012 - Browse Author Resources Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …
  18. psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
    September 01, 2017 - Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks Citation Text: Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33607/psn-pdf
    September 27, 2022 - Burnout September 27, 2022 Yellowlees P, Rea M. Burnout. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/burnout Originally published in December 2011 by researchers at the University of California, San Francisco. Updated in September 2022 by Peter Yellowlees, MD and Margaret Rea, PhD. PSNet primers are regu…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72689/psn-pdf
    January 29, 2021 - But See the Patient First January 29, 2021 Sinigayan VR. But See the Patient First. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/see-patient-first The Case   A 55-year-old man with acute myeloid leukemia presented to the emergency department (ED) with a chief complaint of fever. Five days previously, he …

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