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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
December 01, 2017 - The Society for Thoracic Surgeons National Database is a great example of where most hospitals participate
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - The Society of Thoracic Surgeons (STS) has therefore developed a composite hospital performance measure
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psnet.ahrq.gov/node/74830/psn-pdf
June 01, 2022 - Norris AH, Shrestha NK, Allison GM, et al. 2018 Infectious Diseases Society of America Clinical
Practice
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psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
July 23, 2024 - emotionally and financially devastating to families and result in long-term costs to providers and society
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psnet.ahrq.gov/node/867651/psn-pdf
February 26, 2025 - This framework is perpetuated by requirements imposed by hospital, society, and governing bodies for
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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - American Society of Health-System Pharmacists.
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psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - Change Needed/Quality Improvement Approach
Streamlined TPN re-ordering process
The American Society
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - International journal for quality in health care: journal of the International Society for Quality in
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psnet.ahrq.gov/node/33608/psn-pdf
February 01, 2024 - American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine.
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psnet.ahrq.gov/node/60363/psn-pdf
March 01, 2021 - Journal of the American Geriatrics Society. 2004;52(11):1817-
1825.
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - Fligelstone L, Keating J, et al; Association of Coloproctology of Great Britain and Ireland, the Vascular Society
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - recurrent and injurious falls. 13 Although it is not an exhaustive list, The American Geriatrics Society
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psnet.ahrq.gov/primer/maternal-safety
January 10, 2024 - Millwood) . 2013;32(3):527-535. [ Free full text ] American College of Obstetricians and Gynecologists; Society
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psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
October 02, 2024 - This framework is perpetuated by requirements imposed by hospital, society, and governing bodies for
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - Stroke Consortium, the Canadian Cardiovascular Pharmacists Network, and the Canadian Cardiovascular Society
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psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - Rosenbloom AL, Silverstein JH, Amemiya S, Zeitler P, Klingensmith GJ: International Society for Pediatric
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - SPOTLIGHT CASE
Suicidal Ideation in the Family Medicine Clinic
Citation Text:
Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
…
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - SPOTLIGHT CASE
Don't Dismiss the Dangerous: Obstetric Hemorrhage
Citation Text:
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
…
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psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
July 01, 2008 - Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy
Citation Text:
Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
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psnet.ahrq.gov/node/49813/psn-pdf
January 01, 2018 - Dying in the Hospital With Advanced Dementia
December 1, 2017
Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
Case Objectives
Recognize the importance of eliciting patient preferences and go…