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psnet.ahrq.gov/node/49737/psn-pdf
June 01, 2015 - Unseen Perils of Urinary Catheters
June 1, 2015
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
The Case
A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - SPOTLIGHT CASE
Another Fall
Citation Text:
Bogardus SG. Another Fall. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - SPOTLIGHT CASE
CME/MOC
Delayed Diagnosis of Mesenteric Ischemia
Citation Text:
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - SPOTLIGHT CASE
Patient Safety Events Involving Opioid Dose Stacking
Citation Text:
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
November 10, 2015 - Are We Getting Better at Measuring Patient Safety?
Amy K. Rosen, PhD | November 1, 2010
View more articles from the same authors.
Citation Text:
Rosen AK. Are We Getting Better at Measuring Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare R…
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - wild dream or not, but
there was nothing like an autopsy to sensitize you to the limitations of our skills
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psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
November 01, 2017 - patient awareness, limited health literacy, lower socioeconomic status, older age, inadequate computer skills
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psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
March 01, 2014 - You'll need to make sure people have the skills.
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - Resources Used and Skills Needed
Staffing: Total staffing for the program is approximately 120 paid
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psnet.ahrq.gov/node/841467/psn-pdf
December 14, 2022 - Assess and address gaps in knowledge and/or skills.
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
May 01, 2009 - What have you learned and how would you change the educational process so that people have the skills
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psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
November 01, 2017 - patient awareness, limited health literacy, lower socioeconomic status, older age, inadequate computer skills
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psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - Resources Used and Skills Needed
Resources to implement and operate a large-scale initiative in support
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psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - You'll need to make sure people have the skills.
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psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
March 29, 2023 - Transferring information efficiently requires practice; it has been proposed that clinical handover skills
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psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_hindsight_is_2020_slides_final.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Hindsight is 2020_SLIDES_FINAL.pptx
Spotlight
Hindsight is 20/20: Thrombolytics for Alcohol
Intoxication
Source and Credits
• This presentation is based on the April 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is avail…
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psnet.ahrq.gov/web-mm/pill-organizing-plight
June 19, 2018 - SPOTLIGHT CASE
A Pill Organizing Plight
Citation Text:
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Google Scholar BibTe…
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psnet.ahrq.gov/node/843051/psn-pdf
February 01, 2023 - Respiratory Distress after Neck Surgery: Two Cases of
Postoperative Cervical Hematoma.
February 1, 2023
Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical
Hematoma. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-…
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psnet.ahrq.gov/node/49768/psn-pdf
September 01, 2016 - A Pill Organizing Plight
September 1, 2016
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/pill-organizing-plight
Case Objectives
Identify patients at high risk for adverse drug events.
List drugs that are considered inappropriate in older patients.
…
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - Unseen Perils of Urinary Catheters
Citation Text:
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar Bib…