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psnet.ahrq.gov/web-mm/worst-headache
July 01, 2016 - The Worst Headache
Citation Text:
Edlow JA. The Worst Headache. 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/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
January 01, 2024 - Spotlight
Spotlight
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
1
Source and Credits
This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Garth Utter, MD, MSc, FACS…
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psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
July 08, 2022 - attention to the risk of latex products represents an opportunity to improve health system safety in two ways
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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.
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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…
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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…
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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.
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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.
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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
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Citation Text:
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for…
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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.
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?
Citation Text:
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
C…
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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
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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.
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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.
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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…
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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 …
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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 …
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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.…
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - Missed CANDOR Implementation Opportunities.
November 16, 2022
Schweitzer L. Missed CANDOR Implementation Opportunities. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
The Case
A 58-year-old man with a history of type 2 diabetes mellitus, hypertension, morbid obesit…
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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…