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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - Annual Perspective
Rethinking Root Cause Analysis
Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD | January 1, 2016
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Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. Rockville (MD): Age…
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psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - The Dangerous Detour
Citation Text:
Gibson J, HTaylor D. The Dangerous Detour. 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/dont-bite-your-tongue
September 18, 2024 - Don’t Bite Your Tongue.
Citation Text:
Singh NS. Don’t Bite Your Tongue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/turn-other-cheek
October 26, 2010 - Turn the Other Cheek
Citation Text:
Starling J. Turn the Other Cheek. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
February 26, 2025 - “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV)
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June 30, 2021
Innovat…
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psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
February 01, 2013 - Patient Engagement and Patient Safety
Saul N. Weingart, MD, PhD | February 1, 2013
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Citation Text:
Weingart SN. Patient Engagement and Patient Safety. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA
December 1, 2006
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Citation Text:
In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006.In Conversation with...J. Bryan Sexton, PhD, MA. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
December 01, 2010 - In Conversation with...Geri Amori, PhD
December 1, 2010
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Citation Text:
In Conversation with..Geri Amori, PhD. PSNet [internet]. 2010.In Conversation with...Geri Amori, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/node/72586/psn-pdf
December 23, 2020 - Code Status vs. Care Status
December 23, 2020
Krisman RK, Spero H. Code Status vs. Care Status. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/code-status-vs-care-status
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for
Continuing Medical Education (AC…
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - Establishing a Safety Culture: Thinking Small
Timothy J. Hoff, PhD | December 1, 2006
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Citation Text:
Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. Rockville (MD): Age…
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psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
August 04, 2021 - SPOTLIGHT CASE
The NSTEMI Curbside Consultation
Citation Text:
Villablanca AC, Wong GX. The NSTEMI Curbside Consultation. 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/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - Spotlight
Spotlight
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
1
Source and Credits
This presentation is based on the September 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: David…
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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/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia
Citation Text:
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. 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/49403/psn-pdf
June 01, 2003 - Missed Appendicitis
June 1, 2003
Adams JG. Missed Appendicitis. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missed-appendicitis
Case Objectives
Appreciate the variable presentations of appendicitis
List complications of missed appendicitis
Understand the advantages and disadvantages of CT in diagnosing…
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psnet.ahrq.gov/node/49872/psn-pdf
August 08, 2019 - Spinal Epidural Abscess
August 8, 2019
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess
The Case
A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a
few days of progressive low back pain. She…
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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - The Dropped Lung
Citation Text:
Heffner JR. The Dropped Lung. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - Electronic Err
Citation Text:
Tang PC. Electronic Err. 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/web-mm/milliliters-vs-milligrams
September 01, 2004 - Milliliters vs. Milligrams
Citation Text:
Poole RL, Dixon T. Milliliters vs. Milligrams. 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/node/49638/psn-pdf
January 01, 2012 - Communication Failure—Who's in Charge?
October 1, 2011
Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge
The Case
A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu…