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  1. 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:…
  2. psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
    January 31, 2024 - If the male patient has a history of previous IUC and/or an enlarged prostate, the clinician should probably
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49759/psn-pdf
    May 01, 2016 - Falling Through the Crack (in the Bedrails) May 1, 2016 Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/falling-through-crack-bedrails Case Objectives Review the epidemiology of patient falls and associated injuries in the hospital set…
  4. psnet.ahrq.gov/web-mm/mobility-lost-icu
    August 01, 2018 - SPOTLIGHT CASE Mobility Lost in the ICU Citation Text: Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…
  5. psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
    March 01, 2018 - SPOTLIGHT CASE Difficult Encounters: A CMO and CNO Respond Citation Text: Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: …
  6. psnet.ahrq.gov/web-mm/lot-pain-medications
    September 23, 2020 - SPOTLIGHT CASE A Lot of Pain (Medications) Citation Text: Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…
  7. 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…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49682/psn-pdf
    April 01, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case April 1, 2013 Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premat…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843051/psn-pdf
    February 01, 2023 - Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. February 1, 2023 Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49564/psn-pdf
    July 01, 2008 - Dependence vs. Pain July 1, 2008 Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dependence-vs-pain Case Objectives Define opioid dependence and opioid withdrawal syndrome. Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid Withdra…
  11. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
    January 01, 2022 - Spotlight Spotlight A Case of Mistaken Capacity: Why a Thorough Psychosocial History Can Improve Care Source and Credits • This presentation is based on the March 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: Katrina Pasao, MD…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843150/psn-pdf
    December 05, 2022 - In Conversation with... Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population February 1, 2023 In Conversation with.. Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-connor-wesley-rn-bsn-patie…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73906/psn-pdf
    October 06, 2021 - That was a failure to not have an interpreter, have a Spanish-speaking clinician, or have a handout
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836879/psn-pdf
    April 27, 2022 - that a problem being repeatedly pointed out in the medical literature didn’t automatically change clinician
  15. 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 …
  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/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…
  18. psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
    March 01, 2015 - In Conversation With… Brian Jarman, PhD March 1, 2015  Also Read an Essay Citation Text: In Conversation With… Brian Jarman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy…
  19. 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…
  20. psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
    August 14, 2024 - SPOTLIGHT CASE Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. Citation Text: Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…

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