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psnet.ahrq.gov/perspective/safety-radiology
October 01, 2013 - be able to make this widely available as a first step towards collecting CT radiation dose data to determine
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psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
January 01, 2008 - recommends that certain initiatives be incorporated into our Annual Corporate Accountabilities, which determine
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psnet.ahrq.gov/perspective/conversation-susan-smith-md
August 01, 2019 - scribes requires collaboration among several health care organization stakeholders: administration to determine
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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - reducing the risk of adverse events during the pandemic, researchers and policymakers will need to determine
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psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Intraosseous Line Extravasation in a
Pediatric Trauma Patient
Source and Credits
• This presentation is based on the April 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: David Barnes, MD and Joseph Yoon, MD
o…
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psnet.ahrq.gov/node/836892/psn-pdf
April 07, 2022 - The University of Michigan Emergency Critical Care
Center (EC3) Provides Timely Intensive Care to Critically
Ill Patients in the Emergency Department
April 7, 2022
https://psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-
intensive-care
Summary
An increasing volume…
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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…
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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…
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psnet.ahrq.gov/node/49566/psn-pdf
July 01, 2008 - What Was in Those Platelets?
July 1, 2008
Yomtovian R. What Was in Those Platelets? . PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/what-was-those-platelets
The Case
A 47-year-old woman was admitted to the hospital for complex spinal surgery. The surgery went well
without complications, and postoperativel…
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psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.
Citation Text:
Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.. PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/web-mm/pill-organizing-plight
June 19, 2018 - SPOTLIGHT CASE
A Pill Organizing Plight
Citation Text:
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTe…
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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…
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psnet.ahrq.gov/web-mm/deadly-duo
April 28, 2021 - The Deadly Duo
Citation Text:
Maldonado JR. The Deadly Duo. 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 XML Endnote tagged PubMedId RIS
…
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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…
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care
Following Cesarean Delivery.
November 25, 2020
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean
Delivery. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesare…
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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…
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psnet.ahrq.gov/node/867653/psn-pdf
February 26, 2025 - In Conversation with Jessica Behrhorst about The
Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. In Conversation with Jessica Behrhorst about The Evolution of Root Cause
Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evoluti…
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - SPOTLIGHT CASE
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.
Citation Text:
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/node/838197/psn-pdf
September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a
Plan.
September 28, 2022
Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a Plan. PSNet [internet]. 2022.
https://psnet.…