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  1. psnet.ahrq.gov/web-mm/silent-pain-neck
    August 19, 2020 - Silent Pain in the Neck Citation Text: Bittner EA. Silent Pain in the Neck. 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 EndNote 7 XML Endnote tagged Pu…
  2. psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
    July 02, 2019 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication Citation Text: Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
  3. psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
    May 01, 2005 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. Citation Text: Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
  4. psnet.ahrq.gov/web-mm/check-wristband
    August 03, 2009 - Check the Wristband Citation Text: Rosenthal M. Check the Wristband. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
  5. psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Elizabeth Gould, NP-C, COR…
  6. psnet.ahrq.gov/web-mm/central-line-clot
    August 04, 2021 - SPOTLIGHT CASE Central Line Clot Citation Text: Randolph AG. Central Line Clot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
  7. psnet.ahrq.gov/web-mm/autopsy-revelation
    December 01, 2007 - Autopsy Revelation Citation Text: Shojania KG. Autopsy Revelation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
  8. Spotlight Nstemi (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-07/spotlight_nstemi.pdf
    January 01, 2020 - Spotlight The NSTEMI Curbside Consultation Source and Credits • This presentation is based on the July 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Amparo C. Villablanca, MD and Gordon Wong, MD MBA o AHRQ WebM&M Editors …
  9. psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
    August 01, 2006 - Tacit Handover, Overt Mishap Citation Text: Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
  10. psnet.ahrq.gov/web-mm/reaction-dye
    March 01, 2007 - Reaction to Dye Citation Text: Cohan R. Reaction to Dye. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  11. psnet.ahrq.gov/web-mm/one-dose-two-errors
    September 29, 2017 - One Dose, Two Errors Citation Text: Filice GA. One Dose, Two Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
  12. psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
    October 10, 2017 - SPOTLIGHT CASE Discharged with IV antibiotics: When issues arise, who manages the complications? Citation Text: Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
  13. psnet.ahrq.gov/web-mm/production-pressures
    November 16, 2022 - Production Pressures Citation Text: Carayon P. Production Pressures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
  14. psnet.ahrq.gov/web-mm/good-catch-operating-room
    August 27, 2017 - Good Catch in the Operating Room Citation Text: Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  15. psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx Spotlight Code Status vs. Care Status Source and Credits • This presentation is based on the December 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Rebe…
  16. psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
    November 01, 2023 - Inadequate Preanesthetic Evaluation, Airway Trouble Citation Text: Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49829/psn-pdf
    May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857259/psn-pdf
    November 30, 2023 - Medication Mix-Up Leads to Patient Death November 30, 2023 Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death The Case  An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865778/psn-pdf
    May 29, 2024 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement May 29, 2024 Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-complications-unint…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49570/psn-pdf
    October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure? October 1, 2008 Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure Case Objectives Understand the complementary abilities of an electronic health record a…

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