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  1. 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…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865309/psn-pdf
    May 29, 2024 - A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care May 29, 2024 Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post- Tracheostomy Care. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-i…

  3. 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…

  4. 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-…

  5. 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…

  6. 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…

  7. 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…

  8. 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…

  9. 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…

  10. 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…

  11. 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…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850450/psn-pdf
    June 14, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. June 14, 2023 Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49792/psn-pdf
    May 01, 2017 - Diagnostic Delay in the Emergency Department May 1, 2017 Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department Case Objectives Appreciate the importance of a broad differential diagnosis for acute abdominal pai…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33759/psn-pdf
    October 01, 2012 - Promising Areas for Patient Safety Research December 1, 2003 Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. PSNet [internet]. 2003. https://psnet.ahrq.gov/perspective/promising-areas-patient-safety-research Perspective Setting a Course for Patient Safety Research Although patient safety…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33760/psn-pdf
    February 01, 2014 - In Conversation With… Enrico Coiera, MB, BS, PhD February 1, 2014 In Conversation With… Enrico Coiera, MB, BS, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd Editor's note: Enrico Coiera, MB, BS, PhD, is a professor and director of the Centre for Health Informa…

  16. Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx Spotlight Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation Source and Credits • This presentation is based on the March 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/…

  17. 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: …

  18. Hypoxemia after Emergency Intubation | PSNet

    psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
    March 24, 2019 - Hypoxemia after Emergency Intubation Citation Text: Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

  19. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis | PSNet

    psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
    January 13, 2010 - SPOTLIGHT CASE A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis Citation Text: Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…

  20. Patient Safety Events Involving Opioid Dose Stacking | PSNet

    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. Copy Cita…
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