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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49392/psn-pdf
    April 01, 2003 - Another Fall April 1, 2003 Bogardus SG. Another Fall. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/another-fall Case Objectives List risk factors for falls in hospitalized patients Understand appropriate use of restraints Identify system issues contributing to falls in hospitalized patients Case & Comm…
  2. psnet.ahrq.gov/web-mm/dropping-new-lows
    December 18, 2024 - SPOTLIGHT CASE Dropping to New Lows Citation Text: Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…
  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/865884/psn-pdf
    May 29, 2024 - Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. May 29, 2024 Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-…
  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. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33855/psn-pdf
    April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM April 1, 2018 In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and Directo…
  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/837963/psn-pdf
    August 31, 2022 - Delayed Diagnosis of Mesenteric Ischemia August 31, 2022 Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49737/psn-pdf
    June 01, 2015 - Unseen Perils of Urinary Catheters June 1, 2015 Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters The Case A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49721/psn-pdf
    December 01, 2014 - Ebola: Are We Ready? December 1, 2014 Barsuk JH, Barnard C. Ebola: Are We Ready? PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/ebola-are-we-ready The Case A 28-year-old man, well-appearing but pale, walked into the emergency department (ED) on a Wednesday afternoon at 3 PM complaining of nausea, vomiting,…
  11. psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
    September 25, 2019 - SPOTLIGHT CASE Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. Citation Text: Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research …
  12. psnet.ahrq.gov/web-mm/another-fall
    June 01, 2010 - SPOTLIGHT CASE Another Fall Citation Text: Bogardus SG. Another Fall. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
  13. psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
    January 31, 2024 - Annual Perspective Improving Diagnostic Safety and Quality Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD | April 26, 2023  View more articles from the same authors. Citation Text: Al-Khafaji J, Lee M, Mossburg S. Improving Di…
  14. 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. Copy Cit…
  15. psnet.ahrq.gov/curated-library/patient-team-member-clinical-care
    March 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Patient as a Team Member in Clinical Care  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybraria…
  16. psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
    July 21, 2020 - SPOTLIGHT CASE Anemia and Delayed Colon Cancer Diagnosis Citation Text: Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …
  17. 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…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50841/psn-pdf
    January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near- Miss Wrong Transfusion Event January 29, 2020 Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
  19. psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
    September 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Implementation of Patient Safety Projects  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybraria…
  20. 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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