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  1. psnet.ahrq.gov/perspective/conversation-maureen-bisognano
    February 26, 2025 - In Conversation With… Maureen Bisognano June 1, 2015  Citation Text: In Conversation With… Maureen Bisognano. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72517/psn-pdf
    November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. November 25, 2020 Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesare…
  3. psnet.ahrq.gov/web-mm/getting-root-matter
    September 01, 2005 - SPOTLIGHT CASE Getting to the Root of the Matter Citation Text: Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Schola…
  4. 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…
  5. psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
    February 10, 2021 - SPOTLIGHT CASE A Fatal Twist in Pseudohyperkalemia Citation Text: Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …
  6. psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
    July 01, 2017 - SPOTLIGHT CASE “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event Citation Text: Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
  7. psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
    August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD August 1, 2016  Also Read an Essay Citation Text: In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Heal…
  8. psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
    September 18, 2024 - SPOTLIGHT CASE Diagnostic Delay in the Emergency Department Citation Text: Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format:…
  9. 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…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72516/psn-pdf
    November 25, 2020 - Premature Closure: Was It Just Syncope? November 25, 2020 Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49483/psn-pdf
    June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865429/psn-pdf
    April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery April 24, 2024 Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery…
  13. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
    January 01, 2024 - Spotlight Spotlight Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Christian Bohringer, MBBS, …
  14. 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…
  15. psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
    November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. Citation Text: Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
  16. psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - SPOTLIGHT CASE Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Citation Text: Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
  17. psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
    October 02, 2024 - Safety I, Safety II, and the New Views of Safety Citation Text: Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX E…
  18. psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
    December 23, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication Citation Text: Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Cit…
  19. psnet.ahrq.gov/perspective/safety-dentistry
    August 01, 2016 - Safety In Dentistry Rachel Badovinac Ramoni, DMD, ScD; Muhammad Walji, PhD; and Elsbeth Kalenderian, DDS, MPH, PhD | August 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Ramoni R, Walji MF, Kalenderian E. Safety In De…
  20. psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
    September 01, 2012 - In Conversation With… Jack Needleman, PhD September 1, 2012  Also Read an Essay Citation Text: In Conversation With… Jack Needleman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012…

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