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psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
August 21, 2005 - Patient Allergies and Electronic Health Records
Citation Text:
Doyle MJ. Patient Allergies and Electronic Health Records. 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/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
August 01, 2009 - Spotlight Case July 2008
Spotlight Case
Nurse Staffing Ratios:
The Crucible of Money, Policy, Research, and Patient Care
*
Source and Credits
This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME/CEU credit is available
Commentary by: …
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
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psnet.ahrq.gov/node/866847/psn-pdf
September 25, 2024 - In Conversation with Carole Stockmeier about Zero Harm:
Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 25, 2024
Stockmeier CA, Mossburg S, Lee M. In Conversation with Carole Stockmeier about Zero Harm: Striving to
Reduce Preventable Harms – Point, Counterpoint, and Are…
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psnet.ahrq.gov/node/49781/psn-pdf
January 01, 2017 - Hazards of Loading Doses
January 1, 2017
Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hazards-loading-doses
The Case
A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac
arrest. Two days after discharg…
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psnet.ahrq.gov/primer/opioid-safety
December 15, 2024 - Opioid Safety
Citation Text:
Opioid Safety. 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/perspective/maternal-safety
January 01, 2015 - Annual Perspective
Maternal Safety
Audrey Lyndon, RN, PhD | December 22, 2018
View more articles from the same authors.
Citation Text:
Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…
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psnet.ahrq.gov/node/867035/psn-pdf
October 30, 2024 - A Tale of Two Falls
October 30, 2024
Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/tale-two-falls
The Cases
Case #1: A 79-year-old woman with a history of impaired cognition at baseline was brought from a skilled
nursing facility to the emergency department (ED) f…
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - A Tale of Two Falls
Citation Text:
Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/primer/maternal-safety
January 10, 2024 - Maternal Safety
Citation Text:
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
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psnet.ahrq.gov/periodic-issue/periodic-issue-296
June 30, 2021 - This report examines a long-term situation that, due to failure of reporting and other system issues,
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psnet.ahrq.gov/periodic-issue/periodic-issue-417
November 29, 2023 - 3,986 registered nurses, the majority (83%) reported alarm fatigue and over half (55%) experienced a situation
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psnet.ahrq.gov/periodic-issue/periodic-issue-374
December 14, 2022 - inconsistent preparedness throughout commercial aviation to support care during an in-flight medical situation
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psnet.ahrq.gov/web-mm/silent-pain-neck
August 19, 2020 - It cannot be emphasized enough that this is a high-pressure and risky situation, and the caregivers should
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - The resident, probably intimidated by the situation he found himself in, haltingly began to discuss the
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - Anticoagulant therapy used during PCI varies depending on the operator and the clinical situation but
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - By Vijay Agusala, MD, MBA, James Deen, MD and Saul Schaefer, MD This case represents an unfortunate situation
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psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
August 02, 2015 - This system allows any provider to submit an online report of any situation that created a near miss
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - they could know that the assessment
had been done hours earlier and was now irrelevant to the current situation
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psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - continuous positive airway pressure via face mask, and sitting him upright might have stabilized the situation