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  1. psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Andrew P.J. …
  2. psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
    March 01, 2007 - The Role of the Patient in Improving Patient Safety Rosemary Gibson, MSc | March 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. Rockville…
  3. psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
    January 01, 2014 - SPOTLIGHT CASE Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad Citation Text: Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citatio…
  4. psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
    June 01, 2007 - Advancing Patient Safety Through State Reporting Systems Jill Rosenthal, MPH | June 1, 2007  View more articles from the same authors. Citation Text: Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for…
  5. psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
    August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment Citation Text: Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citatio…
  6. psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
    April 01, 2015 - SPOTLIGHT CASE Pseudo-obstruction But a Real Perforation Citation Text: Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: …
  7. psnet.ahrq.gov/web-mm/lost-transition
    November 17, 2010 - SPOTLIGHT CASE Lost in Transition Citation Text: Beach C. Lost in Transition. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
  8. psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
    July 01, 2012 - EMR Entry Error: Not So Benign Citation Text: Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74713/psn-pdf
    January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking January 26, 2022 Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking Disclosure of Relevant Financial Relationships: As a provider ac…
  10. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
    January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 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: Hollie Porras, PharmD, BCPS and Cathy Lammers…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866992/psn-pdf
    May 29, 2024 - Harm Reduction Strategies to Improve Safety for People Who Use Substances October 30, 2024 Salisbury-Afshar E, Gale B, Mossburg S. Harm Reduction Strategies to Improve Safety for People Who Use Substances . PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-w…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72835/psn-pdf
    March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy March 10, 2021 In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family Cente…
  13. psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
    November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures Citation Text: Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
  14. psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
    February 01, 2023 - SPOTLIGHT CASE When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Citation Text: Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…
  15. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
    January 01, 2020 - Spotlight Spotlight Some Patients Can’t Wait: Improving Timeliness of Emergency Department Care Source and Credits • This presentation is based on the 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm • Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD ○ Editor…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49825/psn-pdf
    April 01, 2018 - When Patients and Providers Speak Different Languages April 1, 2018 Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages Case Objectives Understand the legal and regulatory obligations to prov…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49858/psn-pdf
    April 01, 2019 - What Happened on Telemetry? April 1, 2019 Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/what-happened-telemetry Case Objectives Describe current hospital practices for continuous telemetry monitoring. Appreciate key recommendations from the Update to Practice…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61082/psn-pdf
    July 23, 2020 - Long-Term Care and the Response to COVID-19 October 28, 2020 Popejoy LL, Crecelius CA, Fitall E, et al. Long-Term Care and the Response to COVID-19. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/long-term-care-and-response-covid-19 The COVID-19 pandemic has had far-reaching consequences on how the hea…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49771/psn-pdf
    July 01, 2016 - Unintended Consequences of CPOE October 1, 2016 Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe Case Objectives Explain how technology, including computerized provider order entry, can transform, rather than eliminate, hazards. Recogni…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33690/psn-pdf
    December 01, 2009 - In Conversation with…Gerald B. Hickson, MD December 1, 2009 In Conversation with…Gerald B. Hickson, MD . PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md Editor's note: Gerald B. Hickson, MD, is one of the world's leading experts on physician behavior and its connecti…

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