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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd
February 01, 2006 - In Conversation with…John Banja, PhD
February 1, 2006
Also Read an Essay
Citation Text:
In Conversation with…John Banja, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
October 30, 2024 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an
Order is Not Enough
April 28, 2021
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
Disclosure of Relev…
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psnet.ahrq.gov/node/849661/psn-pdf
June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
June 28, 2023
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During
Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web…
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psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
January 01, 2024 - Spotlight
Spotlight
Missed Connection: A Case of Inadequate ECG
Oversight in Cardiac Surgery
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Christian Bohringer, MBBS, …
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psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight
in Cardiac Surgery
April 24, 2024
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac
Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery…
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - Complications of ECMO During Transport
April 29, 2020
Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
The Case
A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with
acute on chro…
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psnet.ahrq.gov/node/33804/psn-pdf
March 03, 2016 - In Conversation With… Paul McGann, MD
March 1, 2016
In Conversation With… Paul McGann, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
Editor's note: Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for
Medicare & Medicaid Services (CMS). He…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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psnet.ahrq.gov/node/836879/psn-pdf
April 27, 2022 - In Conversation With... Michael L. Millenson
April 27, 2022
In Conversation With.. Michael L. Millenson. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-michael-l-millenson
December 16, 2021
Editor’s note: Michael L. Millenson is the President of Health Quality Advisors LLC, author of the c…
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - SPOTLIGHT CASE
Getting to the Root of the Matter
Citation Text:
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Schola…
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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer
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July 31, 2023
Innovation
Contact
…
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - SPOTLIGHT CASE
A Laceration that Needed a Proper Exam, Not an X-Ray
Citation Text:
Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed
Diagnoses of Cancer
July 31, 2023
https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
Summary
Concern over patient safety issues associated with inadequate tracking of test results has grown over the
last decade, a…
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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.
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - SPOTLIGHT CASE
What Happened on Telemetry?
Citation Text:
Sandau KE, Funk M. What Happened on Telemetry?. 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/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-postdischarge-needs
March 27, 2024 - Transition Coaches® Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs
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June 12, 2020
Innovation
Contact
…