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psnet.ahrq.gov/web-mm/deadly-duo
April 28, 2021 - The Deadly Duo
Citation Text:
Maldonado JR. The Deadly Duo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - SPOTLIGHT CASE
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.
Citation Text:
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/node/73128/psn-pdf
July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions,
and Complications and Enhances Satisfaction for Elderly
Patients.
April 7, 2021
https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-
and-enhances
Summary
The Hospital at Homesm program provides hospital-level care…
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psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.
Citation Text:
Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.. PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - SPOTLIGHT CASE
Too Many Cooks in the Kitchen
Citation Text:
Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - SPOTLIGHT CASE
A Lot of Pain (Medications)
Citation Text:
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - In Conversation With… Gordon Schiff, MD
July 1, 2018
Citation Text:
In Conversation With… Gordon Schiff, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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…
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psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Intraosseous Line Extravasation in a
Pediatric Trauma Patient
Source and Credits
• This presentation is based on the April 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: David Barnes, MD and Joseph Yoon, MD
o…
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psnet.ahrq.gov/node/60267/psn-pdf
March 01, 2021 - Affordable Housing Community Offers Seniors Onsite
Health Care Coordination and Support, Reducing Hospital
Admissions and Falls and Improving Resident Health
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-h…
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - Care Managers Use Software-Aided Medication Review
Protocol for Frail, Community-Dwelling Seniors, Leading
to More Appropriate Medication Use
March 31, 2021
https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-
community-dwelling
Summary
Care management staff (such …
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psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
March 27, 2024 - Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - In Conversation with Timothy Vogus about High
Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization
(HRO) Principles and Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/persp…
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psnet.ahrq.gov/node/846126/psn-pdf
March 09, 2023 - Medication Handling and Compounding Errors in the
Operating Room.
March 15, 2023
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating
Room. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
The Case
A 62-y…
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psnet.ahrq.gov/node/838197/psn-pdf
September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a
Plan.
September 28, 2022
Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a Plan. PSNet [internet]. 2022.
https://psnet.…
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psnet.ahrq.gov/node/33861/psn-pdf
July 01, 2018 - In Conversation With… Gordon Schiff, MD
July 1, 2018
In Conversation With… Gordon Schiff, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
Editor's note: Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research
and Practice, Associate Pr…
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - SPOTLIGHT CASE
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
Citation Text:
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
September 18, 2024 - SPOTLIGHT CASE
Diagnostic Delay in the Emergency Department
Citation Text:
Marshall K, Singh H. Diagnostic Delay in the Emergency Department. 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/perspective/conversation-dave-debronkart
June 01, 2014 - This situation has the potential to change considerably with the availability of more granular "big data
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - The attending should also be contacted if:
Any trainee feels that a situation is more complicated
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psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
December 01, 2010 - The attending should also be contacted if:
Any trainee feels that a situation is more complicated