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  1. 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…
  2. 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…
  3. psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
    January 29, 2021 - Misconnection Leading to Arterial Thrombosis Citation Text: Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar Bib…
  4. psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
    November 02, 2016 - Promising Areas for Patient Safety Research P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH | December 1, 2003  View more articles from the same authors. Citation Text: Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. …
  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/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
    February 26, 2025 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL July 31, 2023 Innovation Contact …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851389/psn-pdf
    July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer Summary Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, a…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867653/psn-pdf
    February 26, 2025 - In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis February 26, 2025 Behrhorst J, Gale B, Van CM. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evoluti…
  9. psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-registered-nurses-perspective
    June 01, 2016 - Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective Karen Frank, DNP, RN, MSHA | June 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Frank K. Becoming a Certified Professional in Patien…
  10. 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…
  11. 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…
  12. 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…
  13. 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…
  14. 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, …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867429/psn-pdf
    December 18, 2024 - Transferrin If a CSF leak is present and clear fluid is visible from a wound defect, the fluid can be analyzed
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848108/psn-pdf
    April 26, 2023 - commonly implicated as a key contributing factor to sentinel events and patient harm.39  One study that analyzed
  17. psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
    April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety Brian K. Alldredge, PharmD; Mary Anne Koda-Kimble, PharmD | April 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Alldredge BK, Koda-Kimb…
  18. psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
    March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety Jane Ball, PhD, and Peter Griffiths, PhD | March 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient…
  19. 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…
  20. 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…

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