-
psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
-
psnet.ahrq.gov/node/33859/psn-pdf
June 01, 2018 - In Conversation With… Richard Hoppmann, MD
June 1, 2018
In Conversation With… Richard Hoppmann, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md
Editor's note: Dr. Hoppmann is the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor
of Medicine, and Dire…
-
psnet.ahrq.gov/node/846126/psn-pdf
March 09, 2023 - Medication Handling and Compounding Errors in the
Operating Room.
March 15, 2023
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating
Room. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
The Case
A 62-y…
-
psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
March 24, 2021 - SPOTLIGHT CASE
Pitfalls in Diagnosing Necrotizing Fasciitis
Citation Text:
Goh T, Goh LG. Pitfalls in Diagnosing Necrotizing Fasciitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
…
-
psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - Annual Perspective
Ensuring Patient and Workforce Safety Culture in Healthcare
John Murray, Joann Sorra, Bryan Gale, Sarah Mossburg
| March 27, 2024
View more articles from the same authors.
Citation Text:
Murray J, Sorra J, Gale B, et al. Ensuring Patient…
-
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…
-
psnet.ahrq.gov/node/73906/psn-pdf
October 06, 2021 - In Conversation With….Alison Stuebe, MD, MSc and
Kristin Tully, PhD
October 6, 2021
In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
Editor’s Note: Alison Stuebe, MD, MSc, is a…
-
psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Spotlight
Spotlight
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
1
Source and Credits
This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Samantha Brown…
-
psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - In Conversation with Timothy Vogus about High
Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization
(HRO) Principles and Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/persp…
-
psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk
Citation Text:
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quali…
-
psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - Hypoxic Gas Supply from Cross-Connected Pipelines
Citation Text:
Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
Copy Citation
Format:
Google S…
-
psnet.ahrq.gov/web-mm/ebola-are-we-ready
July 01, 2012 - Ebola: Are We Ready?
Citation Text:
Barsuk JH, Barnard C. Ebola: Are We Ready?. 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 XML EndNote 7 XML Endnote tagge…
-
psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
-
psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon
Citation Text:
Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
-
psnet.ahrq.gov/node/867359/psn-pdf
December 18, 2024 - Importance of Following Safe Practices for Infant Feeding
and Handling Expressed Breast Milk
December 18, 2024
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling
Expressed Breast Milk. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/importance-following-saf…
-
psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - SPOTLIGHT CASE
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.
Citation Text:
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
-
psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - SPOTLIGHT CASE
Antiseizure Medication Disorder
Citation Text:
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX En…
-
psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - SPOTLIGHT CASE
What Happened on Telemetry?
Citation Text:
Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNo…
-
psnet.ahrq.gov/issue/brave-men-and-emotional-women-theory-guided-literature-review-gender-bias-health-care-and
June 09, 2021 - psnet
-
psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH
November 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 200…