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  1. Root Cause Analysis Gone Wrong | PSNet

    psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
    August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…

  2. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Jaenic Lee, MD Josh Fernel…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866205/psn-pdf
    July 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. July 10, 2024 Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hemorrhagic-sh…

  4. Silent Pain in the Neck | PSNet

    psnet.ahrq.gov/web-mm/silent-pain-neck
    August 19, 2020 - Silent Pain in the Neck Citation Text: Bittner EA. Silent Pain in the Neck. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

  5. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication | PSNet

    psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
    July 02, 2019 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication Citation Text: Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…

  6. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care 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: Elizabeth Gould, NP-C, COR…

  7. Medication Mix-Up: From Bad to Worse | PSNet

    psnet.ahrq.gov/web-mm/medication-mix-bad-worse
    March 01, 2018 - Medication Mix-Up: From Bad to Worse Citation Text: Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote …

  8. Diagnosing a Missed Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
    October 26, 2022 - Diagnosing a Missed Diagnosis Citation Text: Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…

  9. Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx Spotlight Code Status vs. Care Status Source and Credits • This presentation is based on the December 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Rebe…

  10. The Hidden Danger of Unseen Intravenous Catheters | PSNet

    psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
    October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters Citation Text: Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google S…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49829/psn-pdf
    May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857259/psn-pdf
    November 30, 2023 - Medication Mix-Up Leads to Patient Death November 30, 2023 Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death The Case  An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49779/psn-pdf
    January 01, 2017 - The Empty Bag December 1, 2016 Vincent C. The Empty Bag. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/empty-bag The Case A 90-year-old woman with end-stage dementia was admitted to an acute care hospital for treatment of a hip fracture after a fall at a nursing home. During the hospitalization, her kidne…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49705/psn-pdf
    January 01, 2020 - A "Reflexive" Diagnosis in Primary Care April 1, 2014 Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care Case Objectives Appreciate that primary care doctors may be caring for an increasing number of patients wi…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33668/psn-pdf
    May 01, 2008 - In Conversation with…David W. Bates, MD, MSc May 1, 2008 In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc Editor's note: Dr. David Bates is a Professor at Harvard Medical School, Medical Director of Clinical and Quality …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33822/psn-pdf
    January 01, 2017 - In Conversation With… Paul H. O'Neill, MPA January 1, 2017 In Conversation With… Paul H. O'Neill, MPA. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa Editor's note: Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prio…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865376/psn-pdf
    March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures March 27, 2024 Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841139/psn-pdf
    December 14, 2022 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. December 14, 2022 Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. PSNet [internet]. 2022. https://psnet.ah…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33841/psn-pdf
    September 01, 2017 - In Conversation With… Andrew Gettinger, MD September 1, 2017 In Conversation With… Andrew Gettinger, MD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md Editor's note: Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the Office of Cli…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33849/psn-pdf
    January 01, 2018 - In Conversation With… Robert Hirschtick, MD January 1, 2018 In Conversation With… Robert Hirschtick, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md Editor's note: Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author of a numbe…
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