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  1. psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
    September 16, 2015 - SPOTLIGHT CASE Which Line: Ordering Provider or Proceduralist? Citation Text: Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865884/psn-pdf
    May 29, 2024 - Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. May 29, 2024 Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-…
  3. psnet.ahrq.gov/web-mm/do-not-disturb
    February 03, 2011 - SPOTLIGHT CASE Do Not Disturb! Citation Text: Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
  4. psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
    February 26, 2025 - In Conversation With… Kaveh Shojania, MD November 1, 2015  Citation Text: In Conversation With… Kaveh Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72589/psn-pdf
    December 23, 2020 - Delayed Breast Cancer Diagnosis: A False Sense of Security. December 23, 2020 Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security The Case A 60-year-old woman was se…
  6. psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
    October 02, 2019 - SPOTLIGHT CASE One Toxic Drug Is Not Like Another Citation Text: Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTe…
  7. psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
    February 22, 2017 - SPOTLIGHT CASE Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees Citation Text: Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
  8. psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
    January 31, 2024 - In Conversation With… John D. Birkmeyer, MD May 1, 2015  Citation Text: In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Fo…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863649/psn-pdf
    February 28, 2024 - In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0 February 28, 2024 In Conversation With..Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withstephen-…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33796/psn-pdf
    January 01, 2016 - One is that diagnostic errors are not quite as obvious as a fall or a medication error.
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33866/psn-pdf
    September 01, 2018 - But we still fall short.
  12. psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
    February 26, 2025 - But we still fall short.
  13. psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
    January 31, 2020 - Where did it fall through the cracks? That image finding wasn’t on the problem list.
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60066/psn-pdf
    March 25, 2020 - Most fall somewhere between these extremes.  
  15. psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
    May 01, 2008 - RW: It's interesting that, if you go through that list, it seems that where things might fall apart
  16. psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
    May 01, 2018 - RW: It's interesting that, if you go through that list, it seems that where things might fall apart
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74120/psn-pdf
    November 30, 2021 - The patient re-presented to the ED after a fall at home. He had been living independently.
  18. psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
    August 21, 2005 -  (4) assist with cost issues, especially for Medicare patients whose insurance may change yearly or fall
  19. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
    January 01, 2021 - Blunt spinal trauma, such as a motor vehicle collision or fall, can lead to disruption of normal anatomic
  20. psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
    November 25, 2020 - Most fall somewhere between these extremes.  

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