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psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
December 07, 2009 - SPOTLIGHT CASE
No News May Not Be Good News
Citation Text:
Moore CR. No News May Not Be Good News. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/33771/psn-pdf
August 22, 2014 - Beyond the Hospital: the New Frontier of Patient Safety
August 22, 2014
Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
Perspective
The frontier of patient safety outside the hospital has y…
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psnet.ahrq.gov/web-mm/peripheral-iv-too-long
September 15, 2011 - SPOTLIGHT CASE
Peripheral IV in Too Long
Citation Text:
Fang C-T. Peripheral IV in Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - SPOTLIGHT CASE
Physical Diagnosis: A Lost Art?
Citation Text:
Thompson GR, Verghese A. Physical Diagnosis: A Lost Art?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
January 01, 2014 - SPOTLIGHT CASE
Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad
Citation Text:
Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Delayed Diagnosis of Mesenteric Ischemia
Source and Credits
• This presentation is based on the August 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: Anamaria Robles, MD, and Garth Utter, MD, MSc
o AHRQ WebM&M…
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the
Senior Clinical Data Analyst at Atrium Health, and Rhonda
Dickman, MSN, RN, CPHQ, the Director of the Tennessee
Hospital Association PSO
January 12, 2022
In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and
Rhonda…
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - U.S. Department of Veterans Affairs Medical Center,
Houston, TX, and Baylor College of Medicine Revised
Safer Diagnosis (Safer Dx) Instrument
January 26, 2022
https://psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-
college-medicine
Summary
The Revised Safer Dx Instr…
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions
April 28, 2021
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
The Case
A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and
severe e…
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psnet.ahrq.gov/node/49810/psn-pdf
November 01, 2017 - Palliative Care: Comfort vs. Harm
November 1, 2017
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
Case Objectives
Recognize errors may be difficult to identify in palliative care.
State that medication errors and errors in communica…
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psnet.ahrq.gov/node/49852/psn-pdf
February 01, 2019 - Triaging Interhospital Transfers
February 1, 2019
Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
Case Objectives
Recognize that transfer of patients between acute care hospitals is common.
Realize that the interhospital transfer…
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psnet.ahrq.gov/node/49774/psn-pdf
November 01, 2016 - Don't Dismiss the Dangerous: Obstetric Hemorrhage
November 1, 2016
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
Case Objectives
List the common causes of obstetric hemorrhage and the need for a unit-sta…
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psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
April 12, 2023 - SPOTLIGHT CASE
Triaging Interhospital Transfers
Citation Text:
Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.
Citation Text:
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture-2018-user-database-report
April 22, 2018 - Book/Report
Medical Office Survey on Patient Safety Culture: 2018 User Database Report.
Citation Text:
Medical Office Survey on Patient Safety Culture: 2018 User Database Report. Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AH…
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psnet.ahrq.gov/issue/patient-safety-and-artificial-intelligence-clinical-care
December 21, 2022 - Commentary
Patient safety and artificial intelligence in clinical care.
Citation Text:
Ratwani RM, Bates DW, Classen DC. Patient safety and artificial intelligence in clinical care. JAMA Health Forum. 2024;5(2):e235514. doi:10.1001/jamahealthforum.2023.5514.
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psnet.ahrq.gov/issue/identifying-and-reconciling-patients-allergy-information-within-electronic-health-record
June 15, 2022 - Study
Identifying and reconciling patients' allergy information within the electronic health record.
Citation Text:
Vallamkonda S, Ortega CA, Lo YC, et al. Identifying and reconciling patients' allergy information within the electronic health record. Stud Health Technol Inform. 2022;290:…
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psnet.ahrq.gov/issue/transformational-improvement-quality-care-and-health-systems-next-decade
October 14, 2020 - Commentary
Transformational improvement in quality care and health systems: the next decade.
Citation Text:
Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. Transformational improvement in quality care and health systems: the next decade. BMC Med. 2020;18(1):340. doi:10.1186/s12916-02…
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psnet.ahrq.gov/issue/electronic-health-record-challenges-workarounds-and-solutions-observed-practices-integrating
September 20, 2023 - Study
Electronic health record challenges, workarounds, and solutions observed in practices integrating behavioral health and primary care.
Citation Text:
Cifuentes M, Davis M, Fernald D, et al. Electronic Health Record Challenges, Workarounds, and Solutions Observed in Practices Integra…