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psnet.ahrq.gov/web-mm/outbreak
January 29, 2015 - Outbreak
Citation Text:
Rothman R, Stapleton S. Outbreak. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/not-miscarriage
June 01, 2005 - Not a Miscarriage
Citation Text:
Learman LA. Not a Miscarriage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/issue/clinical-pathway-adherence-and-missed-diagnostic-opportunities-among-children-musculoskeletal
November 08, 2023 - Study
Clinical pathway adherence and missed diagnostic opportunities among children with musculoskeletal infections.
Citation Text:
Grubenhoff JA, Bakel LA, Dominguez F, et al. Clinical pathway adherence and missed diagnostic opportunities among children with musculoskeletal infections. …
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psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
November 13, 2024 - Delayed Diagnosis of Endocrinologic Emergencies
Citation Text:
Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/autopsy-revelation
December 01, 2007 - Autopsy Revelation
Citation Text:
Shojania KG. Autopsy Revelation. 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/issue/thinking-threes-changing-surgical-patient-safety-practices-complex-modern-operating-room
April 28, 2021 - Commentary
Thinking in three's: changing surgical patient safety practices in the complex modern operating room.
Citation Text:
Gibbs VC. Thinking in three's: changing surgical patient safety practices in the complex modern operating room. World J Gastroenterol. 2012;18(46):6712-9. doi:…
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psnet.ahrq.gov/issue/correct-use-inhalers-help-patients-breathe-easier
August 10, 2016 - Newspaper/Magazine Article
Correct use of inhalers: help patients breathe easier.
Citation Text:
Correct use of inhalers: help patients breathe easier. ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - Spinal Epidural Abscess
Citation Text:
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/issue/does-learning-mistakes-have-be-painful-analysis-5-years-experience-leeds-radiology
April 05, 2013 - Study
Does learning from mistakes have to be painful? Analysis of 5 years' experience from the Leeds radiology educational cases meetings identifies common repetitive reporting errors and suggests acknowledging and celebrating excellence (ACE) as a more positive way of teaching the same lessons.
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psnet.ahrq.gov/issue/use-and-implementation-standard-operating-procedures-and-checklists-prehospital-emergency
August 28, 2024 - Review
Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review.
Citation Text:
Chen C, Kan T, Li S, et al. Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a lit…
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psnet.ahrq.gov/issue/impact-clinically-undiagnosed-injuries-survival-estimates
April 03, 2024 - Study
The impact of clinically undiagnosed injuries on survival estimates.
Citation Text:
Gedeborg R, Thiblin I, Byberg L, et al. The impact of clinically undiagnosed injuries on survival estimates. Crit Care Med. 2009;37(2). doi:10.1097/ccm.0b013e318194b164.
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psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
April 28, 2021 - Procedural Mishap: Learning Curve?
Citation Text:
Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/x-ray-flip
August 10, 2019 - X-ray Flip
Citation Text:
Shapiro MJ. X-ray Flip. 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/node/39840/psn-pdf
September 15, 2010 - Wrong-site craniotomy: analysis of 35 cases and systems
for prevention.
September 15, 2010
Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for
prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282.
https://psnet.ahrq.gov/issue/wrong-site-craniotomy-…
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psnet.ahrq.gov/web-mm/coming-short
May 20, 2020 - Coming Up Short
Citation Text:
Hochberg Z'ev. Coming Up Short. 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/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
August 01, 2012 - Spotlight Case
Spotlight Case
No News May Not Be Good News
1
2
Source and Credits
This presentation is based on the August 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…
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psnet.ahrq.gov/node/865479/psn-pdf
April 03, 2024 - Characteristics and contributing factors of diagnostic
error in surgery: analysis of closed medico-legal cases
and complaints in Canada.
April 3, 2024
Kwan JL, Calder LA, Bowman CL, et al. Characteristics and contributing factors of diagnostic error in
surgery: analysis of closed medico-legal cases and complaints …
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psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia
Citation Text:
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…
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psnet.ahrq.gov/node/47126/psn-pdf
May 16, 2018 - Unintended adverse consequences of a clinical decision
support system: two cases.
May 16, 2018
Stone EG. Unintended adverse consequences of a clinical decision support system: two cases. J Am Med
Inform Assoc. 2018;25(5):564-567. doi:10.1093/jamia/ocx096.
https://psnet.ahrq.gov/issue/unintended-adverse-consequence…
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psnet.ahrq.gov/issue/diagnostic-stewardship-leveraging-laboratory-improve-antimicrobial-use
March 15, 2023 - Commentary
Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use.
Citation Text:
Morgan DJ, Malani P, Diekema DJ. Diagnostic Stewardship-Leveraging the Laboratory to Improve Antimicrobial Use. JAMA. 2017;318(7):607-608. doi:10.1001/jama.2017.8531.
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