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psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - Hidden Heparins: HIT Happens
December 1, 2006
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
Case Objectives
Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication,
thrombosis.
Discuss the managem…
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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…
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - Crushing Chest Pain: A Missed Opportunity
January 1, 2004
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
Case Objectives
Appreciate the challenges of diagnosing aortic dissection
Describe a Bayesian approach to dia…
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psnet.ahrq.gov/node/33748/psn-pdf
April 01, 2013 - In Conversation With… Christopher P. Landrigan, MD,
MPH
April 1, 2013
In Conversation With… Christopher P. Landrigan, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
Editor's note: Christopher P. Landrigan, MD, is Associate Professor of Medicine and …
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation
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August 30, 2023
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - SPOTLIGHT CASE
Crushing Chest Pain: A Missed Opportunity
Citation Text:
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - SPOTLIGHT CASE
The Perils of Cross Coverage
Citation Text:
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
August 31, 2022 - SPOTLIGHT CASE
Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.
Citation Text:
Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
June 01, 2004 - SPOTLIGHT CASE
Duty to Disclose Someone Else's Error?
Citation Text:
Gallagher TH. Duty to Disclose Someone Else's Error?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
May 26, 2021 - “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records
Citation Text:
MacDonald S. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis.
Citation Text:
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
December 02, 2020 - SPOTLIGHT CASE
The Lost Start Date: an Unknown Risk of E-prescribing
Citation Text:
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/49750/psn-pdf
January 01, 2016 - A Room Without Orders
January 1, 2016
Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/room-without-orders
Case Objectives
Review a common process for planned direct hospital admissions.
Describe challenges of prioritizing day-to-day patient care activities wi…
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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…
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psnet.ahrq.gov/node/49611/psn-pdf
October 01, 2010 - The Deadly Duo
October 1, 2010
Maldonado JR. The Deadly Duo. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/deadly-duo
The Case
A 29-year-old man with a history of depression and possible psychosis was found unconscious and
unresponsive at home and was brought to the emergency department. He was tachycardi…
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx
Spotlight
Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See…
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psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
April 04, 2018 - SPOTLIGHT CASE
The Pains of Chronic Opioid Usage
Citation Text:
Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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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…
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - SPOTLIGHT CASE
Multifactorial Medication Mishap
Citation Text:
Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
June 01, 2017 - In Conversation With… Paul Aylin, MBChB
June 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Paul Aylin, MBChB. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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