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psnet.ahrq.gov/node/49438/psn-pdf
March 05, 2004 - OR Peeping
March 1, 2004
Mackenzie CF. OR Peeping. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/or-peeping
The Case
A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete
spontaneous abortion (miscarriage).
At this community hospital, a new operating room (OR) su…
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psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.60_slideshow.ppt
May 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case May 2004
Too Tight Control:
The Risks of Intensive Insulin Therapy
Source and Credits
This presentation is based on the May 2004
AHRQ WebM&M Spotlight Case in Medicine
CME credit is available through the Web site
See the full article at http://webmm.ahrq.gov
Comm…
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psnet.ahrq.gov/node/49700/psn-pdf
February 01, 2014 - Nonsustained Ventricular Tachycardia After Acute
Coronary Syndromes: Recognizing High-Risk Patients
February 1, 2014
Piccini JP, Newby KL, Califf R. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes:
Recognizing High-Risk Patients. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/nonsustaine…
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psnet.ahrq.gov/node/49821/psn-pdf
February 01, 2018 - Right Place, Right Drug, Wrong Strength
February 1, 2018
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
The Case
A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area bur…
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psnet.ahrq.gov/node/49551/psn-pdf
December 01, 2007 - Too Hot For Comfort
December 1, 2007
Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/too-hot-comfort
The Case
A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV
antibiotics via a peripheral line in the left antec…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005
View more articles from the same authors.
Citation Text:
Conway JB, Weingart SN. Organizational Change…
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psnet.ahrq.gov/node/49805/psn-pdf
September 01, 2017 - The Forgotten Radiographic Read
September 1, 2017
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read
The Case
A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for
management of inferior…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
August 01, 2012 - Spotlight Case
Spotlight Case
No News May Not Be Good News
1
2
Source and Credits
This presentation is based on the August 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…
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psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - Situational Awareness and Patient Safety
April 1, 2016
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
The Case
A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…
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psnet.ahrq.gov/node/867429/psn-pdf
December 18, 2024 - Management of CSF Leaks After Elective Spine Surgery:
Routine Laminectomy Leads to Fatal Discitis and Sepsis
December 18, 2024
Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine
Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. 2024.
https://psnet.ahrq.gov/w…
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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - Infection After Carpal Tunnel Surgery
August 28, 2024
Szabo RM. Infection After Carpal Tunnel Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
The Case
A woman presented for surgery on her right wrist as a treatment for carpal tunnel syndrome. There were no
repo…
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - SPOTLIGHT CASE
Premature Closure: Was It Just Syncope?
Citation Text:
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citation
Format:
…
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psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd
February 01, 2014 - Examining a total of 5325 interruptions in a pediatric tertiary care setting, Hall and colleagues found
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psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
December 01, 2012 - The AGS has done a good job of examining medications that are not good for the elderly.
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psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - For example, systematically examining the process of care from the patient’s entry point into the hospital
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psnet.ahrq.gov/node/60790/psn-pdf
February 23, 2022 - Dental care utilization: examining the associations between
health services deficits and not having
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psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
March 01, 2011 - We're starting to see studies examining how education can improve handoffs.
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psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
March 01, 2008 - Patient safety climate (PSC) perceptions of frontline staff in acute care hospitals: examining
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - For example, systematically examining the process of care from the patient’s entry point into the hospital