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  1. psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - • These tubes can be placed in a variety of ways.
  2. psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
    May 01, 2018 - SPOTLIGHT CASE Medication Reconciliation: Whose Job Is It? Citation Text: Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Googl…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73526/psn-pdf
    July 28, 2021 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. July 28, 2021 Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions The Case …
  4. psnet.ahrq.gov/web-mm/case-mistaken-intubation
    July 01, 2016 - SPOTLIGHT CASE The Case of Mistaken Intubation Citation Text: Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX End…
  5. psnet.ahrq.gov/web-mm/dangerous-shift
    July 24, 2013 - SPOTLIGHT CASE Dangerous Shift Citation Text: Patterson ES. Dangerous Shift. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
  6. psnet.ahrq.gov/web-mm/signout-fallout
    November 16, 2022 - SPOTLIGHT CASE Signout Fallout Citation Text: Starmer AJ, Landrigan CP. Signout Fallout. 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 EndNote…
  7. psnet.ahrq.gov/perspective/implementing-fall-prevention-program
    November 29, 2023 - Implementing a Fall Prevention Program Frances Healey, RN, PhD | December 1, 2011  View more articles from the same authors. Citation Text: Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
  8. psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
    December 01, 2005 - SPOTLIGHT CASE Unexplained Apnea Under Anesthesia Citation Text: Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX …
  9. psnet.ahrq.gov/web-mm/peripheral-iv-too-long
    September 15, 2011 - SPOTLIGHT CASE Peripheral IV in Too Long Citation Text: Fang C-T. Peripheral IV in Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49822/psn-pdf
    March 01, 2018 - Isolated Clot, Real Error March 1, 2018 Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/isolated-clot-real-error Case Objectives Appreciate that errors are common in the management of venous thromboembolism disease. Describe patients with venous thromboembolism i…
  11. psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
    January 17, 2018 - SPOTLIGHT CASE Physical Diagnosis: A Lost Art? Citation Text: Thompson GR, Verghese A. Physical Diagnosis: A Lost Art?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Schola…
  12. psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
    April 30, 2014 - SPOTLIGHT CASE Diagnosing Diagnostic Mistakes Citation Text: McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google S…
  13. psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
    August 29, 2021 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia Citation Text: Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49546/psn-pdf
    October 17, 2007 - Do Not Disturb! October 1, 2007 Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/do-not-disturb Case Objectives Define professionalism. Discuss behaviors associated with lack of professionalism. Outline steps one should take if a significant breach of professionalism is …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49811/psn-pdf
    November 01, 2017 - Delayed Diagnosis of Endocrinologic Emergencies November 1, 2017 Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies The Cases Case #1: A 47-year-old man with a history of hyperthyroidism and h…
  16. 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…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49807/psn-pdf
    October 01, 2017 - Translating From Normal to Abnormal October 1, 2017 Turner AM. Translating From Normal to Abnormal. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/translating-normal-abnormal Case Objectives Define limited English proficiency. Understand the principal approaches to machine translation. Review the way mach…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865540/psn-pdf
    April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration April 11, 2024 Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration The Case An 82-year-old woman presented to the Emergency Department (ED) for …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837660/psn-pdf
    July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse Outcomes July 8, 2022 Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes The Cases Case 1: A 64-year-old man came in for a routine bron…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49388/psn-pdf
    February 01, 2003 - Unexplained Apnea Under Anesthesia February 1, 2003 Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia Case Objectives Clinical Objectives List the causes of prolonged apnea in the operating room Describe the steps in management …

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