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  1. psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx Spotlight Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities Source and Credits • This presentation is based on the March 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842923/psn-pdf
    February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. February 1, 2023 Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60269/psn-pdf
    April 29, 2020 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? April 29, 2020 Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tiss…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49608/psn-pdf
    August 01, 2010 - Emergent Triage Miss August 1, 2010 Travers D. Emergent Triage Miss. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/emergent-triage-miss The Case A 42-year-old woman presented to a busy urban emergency department (ED) and approached the triage nurse. The patient told the triage nurse that she had "3 days o…
  5. psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
    March 01, 2011 - , as well as what tasks need to be performed (e.g., following up on a pending laboratory test or re-evaluating … A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on
  6. psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
    March 31, 2021 - SPOTLIGHT CASE Delayed Diagnosis of Mesenteric Ischemia Citation Text: Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60610/psn-pdf
    June 24, 2020 - Endometriosis: A Common and Commonly Missed and Delayed Diagnosis June 24, 2020 Mackenzie M, Royce C. Endometriosis: A Common and Commonly Missed and Delayed Diagnosis. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis   The Case A 15-year-old g…
  8. Psn-Pdf (pdf file)

    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-…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861760/psn-pdf
    January 31, 2024 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery January 31, 2024 Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…
  10. psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis
    May 26, 2021 - Endometriosis: A Common and Commonly Missed and Delayed Diagnosis Citation Text: Mackenzie M, Royce C. Endometriosis: A Common and Commonly Missed and Delayed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Cit…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49720/psn-pdf
    December 01, 2014 - A Stroke of Error December 1, 2014 Barrett KM. A Stroke of Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/stroke-error Case Objectives State the key clinical factors to assess in a patient with suspected stroke. Appreciate the relationship between elevated blood pressure and stroke in the acute sett…
  12. psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
    January 01, 2014 - There were significant advances in these areas in 2014, as well as the publication of new evidence evaluatingEvaluating Patient Safety Competencies Among Trainees The Lucian Leape Institute's Unmet Needs report
  13. psnet.ahrq.gov/continuing-education
    February 26, 2025 - The commentary highlights the importance of evaluating patient risk of wound infection and poor wound
  14. psnet.ahrq.gov/primer/patient-safety-indicators
    June 15, 2024 - This transition has prompted a body of research on evaluating, measuring, and preventing patient safety
  15. psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
    October 13, 2018 - A framework for evaluating electronic health record vendor user-centered design and usability testing
  16. psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
    November 27, 2019 - Evaluating the impact of obesity on safety and efficacy of weight-based norepinephrine dosing in septic
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73953/psn-pdf
    October 27, 2021 - Polypharmacy: evaluating risks and deprescribing. Am Fam Physician. 2019;100(1):32-38. 
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867985/psn-pdf
    January 01, 2025 - https://psnet.ahrq.gov/issue/sentinel-event https://psnet.ahrq.gov//#4 https://psnet.ahrq.gov/issue/evaluating-prevalence-four-recommended-practices-suicide-prevention-following-hospital
  19. psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
    July 02, 2019 - Labeling of medicines and patient safety: evaluating methods of reducing drug name confusion. 
  20. psnet.ahrq.gov/web-mm/dressed-failure
    September 01, 2011 - June 3, 2013 The Triangle Model for evaluating the effect of health information technology

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