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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens  
 
 
 
 
 Citation Text: 
 Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. 
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psnet.ahrq.gov/web-mm/blind-spot July 30, 2020 - Blind Spot 
 
 
 
 
 Citation Text: 
 Lee LA. Blind Spot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. 
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 Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS 
 
 
 
 
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psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign July 01, 2012 - EMR Entry Error: Not So Benign 
 
 
 
 
 Citation Text: 
 Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. 
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psnet.ahrq.gov/web-mm/moving-pains August 17, 2017 - SPOTLIGHT CASE
         
 Moving Pains 
 
 
 
 
 Citation Text: 
 Schell H, Wachter R. Moving Pains. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. 
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side August 20, 2018 - A Double “Never Event”: Wrong Patient and Wrong Side. 
 
 
 
 
 Citation Text: 
 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. 
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psnet.ahrq.gov/node/49486/psn-pdf August 21, 2005 - Impatient Inpatient Dosing
August 21, 2005
White RH. Impatient Inpatient Dosing. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
Case Objectives
Appreciate the challenges of initiating warfarin therapy in the hospitalized patient
Understand the fundamental pharmacology of warfarin…  
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation April 01, 2015 - SPOTLIGHT CASE
         
 Pseudo-obstruction But a Real Perforation 
 
 
 
 
 Citation Text: 
 Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. 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/node/49765/psn-pdf August 21, 2016 - Cognitive Overload in the ICU
August 21, 2016
Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/cognitive-overload-icu
Case Objectives
Identify the role of cognitive overload—especially interruptions—in compromising quality of care and
patient safety.
List…  
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psnet.ahrq.gov/node/73336/psn-pdf May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping
Healthcare Providers
May 26, 2021
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
The Case 
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications February 01, 2006 - SPOTLIGHT CASE
         
 Near Miss with Bedside Medications 
 
 
 
 
 Citation Text: 
 Wu AW. Near Miss with Bedside Medications. 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/node/866343/psn-pdf December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure
with Hypertensive Emergency
December 31, 2024
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive
Emergency. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hyperte…  
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psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures 
 
 
 
 
 Citation Text: 
 Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …  
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psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd February 26, 2025 - In Conversation With… Paul G. Shekelle, MD, MPH, PhD 
 October 1, 2011 
                       
 
 
 
 
 
 
 
 
 
 
 
 
 Citation Text: 
 In Conversation With… Paul G. Shekelle, MD, MPH, PhD. 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/anticoagulation-held-too-long April 01, 2008 - Anticoagulation: Held Too Long 
 
 
 
 
 Citation Text: 
 Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. 
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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest February 01, 2023 - SPOTLIGHT CASE
         
 When the Lytes Go Out: A Case of Inpatient Cardiac Arrest  
 
 
 
 
 Citation Text: 
 Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…  
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psnet.ahrq.gov/node/866055/psn-pdf May 29, 2024 - Reducing Preventable Patient Harm Due to Retained
Surgical Items: The RSI Bundle
May 29, 2024
https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
Summary
Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common
catego…  
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psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly June 01, 2015 - SPOTLIGHT CASE
         
 Empiric Steroids: the Good, the Bad, and the Ugly 
 
 
 
 
 Citation Text: 
 Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. 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/node/49807/psn-pdf October 01, 2017 - Translating From Normal to Abnormal
October 1, 2017
Turner AM. Translating From Normal to Abnormal. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/translating-normal-abnormal
Case Objectives
Define limited English proficiency.
Understand the principal approaches to machine translation.
Review the way mach…  
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx
Spotlight
Respiratory Distress after Neck Surgery: Two 
Cases of Post-Operative Cervical Hematoma
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…  
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psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home October 30, 2024 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission 
 
 
 
 
 
 
 
 
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