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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - practitioners about how the organization would like to trade off the associated risks for this and related scenarios … Instead of providing guidance on desired risk trade-offs in particular scenarios, settings, disciplines
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psnet.ahrq.gov/periodic-issue/periodic-issue-411
October 31, 2023 - In-hospital cardiac arrests (IHCAs) are complex clinical scenarios requiring effective communication
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psnet.ahrq.gov/web-mm/lp-or-not-lp
February 01, 2018 - To LP or Not LP
Citation Text:
Landrigan CP. To LP or Not LP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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…
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psnet.ahrq.gov/issue/fatal-case-iatrogenic-hypercalcemia-after-calcium-channel-blocker-overdose
October 26, 2022 - Commentary
A fatal case of iatrogenic hypercalcemia after calcium channel blocker overdose.
Citation Text:
Sim MT, Stevenson FT. A fatal case of iatrogenic hypercalcemia after calcium channel blocker overdose. J Med Toxicol. 2008;4(1):25-9.
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psnet.ahrq.gov/issue/adenocarcinoma-situ-uterine-cervix-screening-and-diagnostic-errors-papanicolaou-smears
July 06, 2011 - Study
Adenocarcinoma in situ of the uterine cervix: screening and diagnostic errors in Papanicolaou smears.
Citation Text:
Ruba S, Schoolland M, Allpress S, et al. Adenocarcinoma in situ of the uterine cervix: screening and diagnostic errors in Papanicolaou smears. Cancer. 2004;102(5):…
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psnet.ahrq.gov/issue/evaluating-service-delivery-interventions-enhance-patient-safety
June 18, 2008 - Study
Evaluating service delivery interventions to enhance patient safety.
Citation Text:
Brown C, Lilford RJ. Evaluating service delivery interventions to enhance patient safety. BMJ. 2008;337:a2764. doi:10.1136/bmj.a2764.
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DOI Google Scholar PubMed …
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psnet.ahrq.gov/web-mm/bleeding-risk
November 01, 2003 - Bleeding Risk
Citation Text:
Crowther MA. Bleeding Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - The Dropped Lung
Citation Text:
Heffner JR. The Dropped Lung. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/its-all-syringe
February 01, 2013 - It's All in the Syringe
Citation Text:
Weingart SN. It's All in the Syringe. 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/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
January 01, 2019 - Spotlight
Spotlight
"Do You Want Everything Done?":
Clarifying Code Status
Source and Credits
• This presentation is based on the December 2019
AHRQ WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Karl Steinberg MD, CMD, HMDC & Thaddeus
M…
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psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - The Case for Patient Flow Management
November 1, 2011
Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/case-patient-flow-management
The Case
A 52-year-old woman with a history of major depression, posttraumatic stress disorder, and alcohol abuse
wa…
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - A Mistaken Dose of Naloxone?
December 18, 2019
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
The Case
A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up
appointment. He h…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
August 01, 2014 - PowerPoint Presentation
Spotlight
Pitfalls in Diagnosing Necrotizing Fasciitis
This presentation is based on the July/August 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Terence Goh, MBBS, Department of Plastic Surgery, Singapore General Hos…
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psnet.ahrq.gov/node/49562/psn-pdf
May 01, 2008 - The Inside of a Time Out
May 1, 2008
Feldman DL. The Inside of a Time Out. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/inside-time-out
The Case
A 65-year-old man was scheduled for an elective endovascular repair of an abdominal aortic aneurysm.
The patient had an allergy to "IV contrast dye" that was no…
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psnet.ahrq.gov/node/49619/psn-pdf
February 01, 2011 - In some clinical scenarios, however, this heuristic fails: patients "look fine," and by the time
the
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psnet.ahrq.gov/issue/delivering-results
August 17, 2016 - Newspaper/Magazine Article
Delivering results.
Citation Text:
Delivering results. Landro L. Wall Street Journal. March 28, 2011.
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psnet.ahrq.gov/issue/disconnected
February 03, 2011 - Commentary
Disconnected.
Citation Text:
Klass P. Disconnected. N Engl J Med. 2010;362(15):1358-61. doi:10.1056/NEJMp0911193.
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psnet.ahrq.gov/issue/why-nurses-make-medication-errors-simulation-study
March 02, 2011 - Study
Why nurses make medication errors: a simulation study.
Citation Text:
Kazaoka T, Ohtsuka K, Ueno K, et al. Why nurses make medication errors: a simulation study. Nurse Educ Today. 2007;27(4):312-7.
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - Missing Trauma
Citation Text:
Jurkovich GJ. Missing Trauma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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