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  1. The Forgotten Turn | PSNet

    psnet.ahrq.gov/web-mm/forgotten-turn
    August 01, 2018 - SPOTLIGHT CASE The Forgotten Turn Citation Text: Barbour S. The Forgotten Turn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851099/psn-pdf
    June 28, 2023 - Misconnection Leading to Arterial Thrombosis June 28, 2023 Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis The Case A 55-year-old man with chronic obstructive pulmonary disease (COPD) was brought by am…

  3. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…

  4. Right Regimen, Wrong Cancer: Patient Catches Medical Error | PSNet

    psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
    August 01, 2006 - SPOTLIGHT CASE Right Regimen, Wrong Cancer: Patient Catches Medical Error Citation Text: Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…

  5. Medication Reconciliation With a Twist (or Dare We Say, a Patch?) | PSNet

    psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
    April 03, 2024 - SPOTLIGHT CASE Medication Reconciliation With a Twist (or Dare We Say, a Patch?) Citation Text: Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…

  6. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation | PSNet

    psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
    September 27, 2023 - SPOTLIGHT CASE Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation Citation Text: Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation. PSNet [internet]. Rockville (MD): Agency for Health…

  7. Don't Dismiss the Dangerous: Obstetric Hemorrhage | PSNet

    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. Copy Citation Format: …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863649/psn-pdf
    February 28, 2024 - In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0 February 28, 2024 In Conversation With..Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withstephen-…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74121/psn-pdf
    November 30, 2021 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. November 30, 2021 Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emerg…

  10. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications | PSNet

    psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
    February 01, 2004 - SPOTLIGHT CASE Delay in Treatment: Failure to Contact Patient Leads to Significant Complications Citation Text: Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50754/psn-pdf
    December 18, 2019 - "Do You Want Everything Done?": Clarifying Code Status December 18, 2019 Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status Disclosure of Relevant Financial Relationships: As a p…

  12. Time of Death? | PSNet

    psnet.ahrq.gov/web-mm/time-death
    January 03, 2017 - Time of Death? Citation Text: Taekman JM, Wright MC. Time of Death?. 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 …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49753/psn-pdf
    February 01, 2016 - Robotic Surgery: Risks vs. Rewards February 1, 2016 Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards Case Objectives Discuss the background and current trends in robotic surgery. Identify the benefits of robotic s…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33869/psn-pdf
    November 01, 2018 - In Conversation With… David Meltzer, MD, PhD November 1, 2018 In Conversation With… David Meltzer, MD, PhD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd Editor's note: Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medici…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33862/psn-pdf
    July 01, 2018 - In Conversation With… Shantanu Nundy, MD July 1, 2018 In Conversation With… Shantanu Nundy, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md Editor's note: Dr. Nundy is the Director of the nonprofit organization called the Human Diagnosis Project, a unique effort to cro…

  16. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
    January 01, 2022 - Spotlight Spotlight Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong Source and Credits • This presentation is based on the October 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838900/psn-pdf
    October 27, 2022 - Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. October 27, 2022 Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/fecal-contamination-…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49491/psn-pdf
    September 01, 2005 - Time of Death? September 1, 2005 Taekman JM, Wright MC. Time of Death? PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/time-death The Case An 80-year-old woman with multiple illnesses, including chronic obstructive pulmonary disease (COPD), was found pulseless and cyanotic in her hospital bed. A code was ca…

  19. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure | PSNet

    psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
    March 01, 2005 - SPOTLIGHT CASE CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure Citation Text: Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33826/psn-pdf
    February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM February 1, 2017 In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am Editor's note: Dr. Edmondson is professor of Leadership and Management at Harvard Business School. Her la…
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