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psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
January 01, 2022 - Spotlight
Spotlight
Fecal Contamination of the Peritoneum from
Laparoscopic Trocar Injury: A Routine
Operation Goes Wrong
Source and Credits
• This presentation is based on the October 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary…
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psnet.ahrq.gov/node/61083/psn-pdf
October 28, 2020 - In Conversation With... Charles A Crecelius, MD, PhD,
CMD and Lori L Popejoy, PhD, RN, FAAN
October 28, 2020
In Conversation With.. Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-charles-crecelius-md-phd-cmd-and-lori-l-po…
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psnet.ahrq.gov/node/72613/psn-pdf
December 22, 2020 - In Conversation With... Elsabeth Kalenderian, DDS, MPH,
PhD and Muhammad F. Walji, PhD
December 22, 2020
In Conversation With.. Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-
w…
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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx
Spotlight
Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/…
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
January 01, 2024 - Spotlight
Spotlight
Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head
1
Source and Credits
This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Ryan Martin, MD, FCNS and …
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psnet.ahrq.gov/node/853081/psn-pdf
August 30, 2023 - In Conversation with... Kathleen Sanford and Sue
Schuelke about Virtual Nursing
August 30, 2023
Sanford K, Schuelke S, Lee M, et al. In Conversation with.. Kathleen Sanford and Sue Schuelke about
Virtual Nursing. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schue…
-
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…
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psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx
Spotlight
A Missed Bowel Perforation – the Importance of
Diagnostic Reasoning
Source and Credits
• This presentation is based on the September 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/web…
-
psnet.ahrq.gov/node/33791/psn-pdf
September 01, 2015 - In Conversation With… Vineet Arora, MD, MAPP
September 1, 2015
In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
Editor's note: Vineet Arora, MD, MAPP, is Director of GME Clinical Learning Environment Innovation,
Associate Pr…
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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…
-
psnet.ahrq.gov/node/33728/psn-pdf
May 01, 2012 - In Conversation With…David C. Classen, MD, MS
May 1, 2012
In Conversation With…David C. Classen, MD, MS. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
Editor's note: David C. Classen, MD, MS, is Chief Medical Information Officer for Pascal Metrics and an
Associa…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Intraoperative Awareness during Rhinoplasty
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Christian Bohringer MBBS and Jaijeet Toor MD
AHRQ WebM&M Edit…
-
psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed
Diagnoses of Cancer
July 31, 2023
https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
Summary
Concern over patient safety issues associated with inadequate tracking of test results has grown over the
last decade, a…
-
psnet.ahrq.gov/node/33858/psn-pdf
May 01, 2018 - In Conversation With… John Halamka, MD, MS
May 1, 2018
In Conversation With… John Halamka, MD, MS. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
Editor's note: Dr. Halamka is the International Healthcare Innovation Professor at Harvard Medical
School, Chief Information …
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psnet.ahrq.gov/node/852700/psn-pdf
August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond
the Pandemic: Creating Total Systems Safety
August 30, 2023
McGaffigan P, Van CM, Mossburg S. In Conversation with.. Patricia McGaffigan about Beyond the
Pandemic: Creating Total Systems Safety . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/con…
-
psnet.ahrq.gov/node/50614/psn-pdf
October 30, 2019 - In Conversation With… Vineet Chopra, MD, MSc
October 30, 2019
In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
Editor's note: Dr. Chopra is Chief of the Division of Hospital Medicine and Associate Professor of
Medicine at the…
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - In Conversation With… Mark L. Graber, MD
January 1, 2016
In Conversation With… Mark L. Graber, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
Editor's note: Dr. Graber is a Senior Fellow at RTI International and Professor Emeritus of Medicine at
the State University o…
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psnet.ahrq.gov/node/33866/psn-pdf
September 01, 2018 - In Conversation With… Sigall K. Bell, MD
September 1, 2018
In Conversation With… Sigall K. Bell, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
Editor's note: Dr. Bell is Director of Patient Safety and Discovery at OpenNotes, Beth Israel Deaconess
Medical Center and As…
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psnet.ahrq.gov/node/867428/psn-pdf
December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing
Journey to Prevent Patient Falls
December 18, 2024
Dykes PC, Sousane Z, Mossburg SE. In Conversation with Patricia Dykes about The Ongoing Journey to
Prevent Patient Falls. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-patricia-dykes-a…