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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
September 27, 2023 - SPOTLIGHT CASE
Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation
Citation Text:
Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation. PSNet [internet]. Rockville (MD): Agency for Health…
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - SPOTLIGHT CASE
Palliative Care: Comfort vs. Harm
Citation Text:
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
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psnet.ahrq.gov/node/49753/psn-pdf
February 01, 2016 - Robotic Surgery: Risks vs. Rewards
February 1, 2016
Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
Case Objectives
Discuss the background and current trends in robotic surgery.
Identify the benefits of robotic s…
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psnet.ahrq.gov/node/857258/psn-pdf
November 30, 2023 - Always Check the Muscle Twitch: Residual
Neuromuscular Block After Removal of a Gastric Balloon
November 30, 2023
Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of
a Gastric Balloon. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/always-check-muscle-twitch-…
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psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
March 01, 2005 - SPOTLIGHT CASE
CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure
Citation Text:
Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…
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psnet.ahrq.gov/curated-library/diagnostic-safety-improvement
July 21, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Diagnostic Safety Improvement
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNe…
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psnet.ahrq.gov/print/pdf/node/838351
July 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Diagnostic Safety Improvement
Curated Library
Foundations
Improving Diagnosis in Health Care.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and
Medicine. Washington, DC: National Academies Press; …
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
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May 29, 2024
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Inno…
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psnet.ahrq.gov/curated-library/value-and-patient-safety
October 30, 2019 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Value and Patient Safety
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Tea…
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psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
December 02, 2020 - SPOTLIGHT CASE
The Lost Start Date: an Unknown Risk of E-prescribing
Citation Text:
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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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/web-mm/all-history
February 28, 2011 - SPOTLIGHT CASE
All in the History
Citation Text:
Fee C. All in the History. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - SPOTLIGHT CASE
The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy
Citation Text:
Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - Misplaced Nasogastric Tube Resulting in Aspiration
Citation Text:
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
Google S…
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psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
February 01, 2019 - Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula
Jed D. Gonzalo, MD, MSc, and Mamta K. Singh, MD, MSc | February 1, 2019
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Citati…
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psnet.ahrq.gov/perspective/conversation-charles-ornstein
October 01, 2009 - In Conversation with... Charles Ornstein
October 1, 2009
Also Read an Essay
Citation Text:
In Conversation with.. Charles Ornstein . PSNet [internet]. 2009.In Conversation with... Charles Ornstein . PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
February 01, 2019 - In Conversation With… Susan E. Skochelak, MD, PhD
February 1, 2019
Also Read an Essay
Citation Text:
In Conversation With… Susan E. Skochelak, MD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
April 24, 2024 - Post-Acute Transitional Services: Safety in Home-Based Care Programs
Citation Text:
McElroy V, Ordona RB, Bakerjian D. Post-Acute Transitional Services: Safety in Home-Based Care Programs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety
Robert M. Wachter, MD | October 1, 2009
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Citation Text:
Wachter R. The Media: An Essential, If Sometimes Arbitrary, Pro…