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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Mismanagement of Delirium
May 1, 2016
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/mismanagement-delirium
The Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although
fitted with a cast at a regional ho…
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psnet.ahrq.gov/node/33839/psn-pdf
August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of
Northwester…
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - In Conversation with…David W. Bates, MD, MSc
May 1, 2008
In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
Editor's note: Dr. David Bates is a Professor at Harvard Medical School, Medical Director of Clinical and
Quality …
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting
firm …
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psnet.ahrq.gov/web-mm/unfamiliar-catheter
November 01, 2006 - The Unfamiliar Catheter
Citation Text:
Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - However, the patient’s condition worsened, and he suddenly developed diffuse peritonitis, signaling failure
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
Citation Text:
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/node/850673/psn-pdf
June 14, 2023 - It came so
suddenly and overwhelmed health systems so fast.
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psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
July 17, 2024 - SPOTLIGHT CASE
Tough Call: Addressing Errors From Previous Providers
Citation Text:
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy…
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psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia
Citation Text:
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
April 19, 2023 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
Citation Text:
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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…
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psnet.ahrq.gov/web-mm/weighing-surgical-safety
August 04, 2021 - SPOTLIGHT CASE
Weighing In on Surgical Safety
Citation Text:
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google Scholar …
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Delayed Diagnosis of Mesenteric Ischemia
Source and Credits
• This presentation is based on the August 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: Anamaria Robles, MD, and Garth Utter, MD, MSc
o AHRQ WebM&M…
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psnet.ahrq.gov/node/60865/psn-pdf
August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-
BC-FACHE
August 31, 2020
In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
Editor’s Note: Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is …
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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - Blind Spot
Citation Text:
Lee LA. Blind Spot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download …
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psnet.ahrq.gov/sites/default/files/2024-11/spotlight_case_neurological_red_flags_final.pptx
January 01, 2024 - Spotlight
Spotlight
Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache
1
Source and Credits
This presentation is based on the November 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Jonatha…
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - By January, very shortly after my announcement of the campaign at our National Forum, we suddenly realized
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psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
December 01, 2014 - You cannot suddenly throw out access to your medical record by mobile phone if you've never talked to
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psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
November 01, 2005 - By January, very shortly after my announcement of the campaign at our National Forum, we suddenly realized
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psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
December 01, 2014 - You cannot suddenly throw out access to your medical record by mobile phone if you've never talked to