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psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - Its Potential Complications Pneumonia remains a common cause for hospitalization of children in the United … States.
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - Assessment of physician prescribing of muscle relaxants in the United States, 2005-2016.
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - like individuals perform the activity; and (4) elimination of unpleasant physiological and affective states
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psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
January 19, 2016 - Bowel Injury After Laparoscopic Surgery
Citation Text:
Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - Pocket Syringe Swap
Citation Text:
Kulli JC. Pocket Syringe Swap. 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/caution-interrupted
October 01, 2016 - Caution, Interrupted
Citation Text:
Wears RL. Caution, Interrupted. 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/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
September 01, 2006 - Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United … States remains far from ideal.( 1 ) It is easy to feel pessimistic.
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - access for many different reasons, 1 with about 200,000-250,000 procedures performed annually in the United … States and a success rate of 95% or higher. 2-6 Decisions about the type of enteral access and the
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psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
August 01, 2015 - Use and characteristics of electronic health record systems among office-based physician practices: United … States, 2001?
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psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
November 15, 2023 - Hospital at Home program has been adopted by 41 hospitals, health systems and intermediaries in the United … States and Canada, including Brigham and Women’s Hospital (Massachusetts), Huntsman Cancer Institute
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - Impact of atrial fibrillation in aortic stenosis (From the United States Readmissions Database).
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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/residual-anesthesia-tepid-burn
February 10, 2010 - Residual Anesthesia: Tepid Burn
Citation Text:
Kurrek MM, Twersky RS. Residual Anesthesia: Tepid Burn. 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/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - you've created the opportunity for everyone to piggyback—the insurance companies can piggyback, the states
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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - you've created the opportunity for everyone to piggyback—the insurance companies can piggyback, the states
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
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psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
January 01, 2020 - some of the advantages in protocol-based management of
complex and rapidly evolving care in disease states
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psnet.ahrq.gov/node/49867/psn-pdf
July 02, 2019 - Diuretics and Electrolyte Abnormalities
July 2, 2019
Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
Case Objectives
Recognize that thiazide diuretics can lead to serious adverse events.
State how commonly used t…
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psnet.ahrq.gov/node/61078/psn-pdf
October 28, 2020 - Inpatient Stroke Management in an Adolescent with Type
1 Diabetes and Home Insulin Pump
October 28, 2020
Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1
Diabetes and Home Insulin Pump . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/inpatient-stroke-management…
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psnet.ahrq.gov/node/49482/psn-pdf
May 01, 2005 - Pregnant With Danger
May 1, 2005
Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pregnant-danger
The Case
A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of
the night complaining of left leg pain. She also had so…