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  1. psnet.ahrq.gov/web-mm/isolated-clot-real-error
    December 01, 2013 - SPOTLIGHT CASE Isolated Clot, Real Error Citation Text: Parks A, Fang MC. Isolated Clot, Real Error. 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…
  2. psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
    March 24, 2019 - Hypoxemia after Emergency Intubation Citation Text: Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…
  3. psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
    July 01, 2008 - Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy Citation Text: Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
  4. psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
    February 26, 2025 - In Conversation With… Eric J. Topol, MD September 1, 2015  Citation Text: In Conversation With… Eric J. Topol, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Form…
  5. psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
    February 01, 2004 - SPOTLIGHT CASE Delay in Treatment: Failure to Contact Patient Leads to Significant Complications Citation Text: Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60977/psn-pdf
    January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication September 30, 2020 Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication The Case A 65-year-old woman co…
  7. psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
    May 31, 2023 - In Conversation With… Vineet Arora, MD, MAPP September 1, 2015  Citation Text: In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citatio…
  8. psnet.ahrq.gov/perspective/conversation-lucian-leape-md
    June 12, 2019 - In Conversation With… Lucian Leape, MD April 1, 2015  Citation Text: In Conversation With… Lucian Leape, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: …
  9. psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
    March 27, 2024 - SPOTLIGHT CASE "Do You Want Everything Done?": Clarifying Code Status Citation Text: Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73128/psn-pdf
    July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. April 7, 2021 https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications- and-enhances Summary The Hospital at Homesm program provides hospital-level care…
  11. psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx Spotlight A Missed Bowel Perforation – the Importance of Diagnostic Reasoning Source and Credits • This presentation is based on the September 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/web…
  12. psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
    April 01, 2005 - In Conversation with…Christopher P. Landrigan, MD April 1, 2005  Also Read an Essay Citation Text: In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
  13. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
    January 01, 2022 - Spotlight Spotlight Intraosseous Line Extravasation in a Pediatric Trauma Patient Source and Credits • This presentation is based on the April 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: David Barnes, MD and Joseph Yoon, MD o…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836892/psn-pdf
    April 07, 2022 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department April 7, 2022 https://psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely- intensive-care Summary An increasing volume…
  15. psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx Spotlight Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotli…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33726/psn-pdf
    March 01, 2012 - In Conversation With… Richard C. Boothman, JD March 1, 2012 In Conversation With… Richard C. Boothman, JD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd Editor's note: Rick Boothman, an attorney, is the chief risk officer for the University of Michigan Health System…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867497/psn-pdf
    February 26, 2025 - Retained Surgical Items: Causation and Prevention February 26, 2025 Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention Background A retained surgical item (RSI) is a surgical patient safety pro…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33791/psn-pdf
    September 01, 2015 - In Conversation With… Vineet Arora, MD, MAPP September 1, 2015 In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp Editor's note: Vineet Arora, MD, MAPP, is Director of GME Clinical Learning Environment Innovation, Associate Pr…
  19. psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
    May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD May 28, 2020  Also Read the Essay Citation Text: In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020.In Conversation With... Jeffrey Shuren, MD, JD. PSNet [internet]. Rockville (MD): Agency for Healt…
  20. psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
    November 25, 2020 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. Citation Text: Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…

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