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181. Spotlight Case Hindsight Is 2020 Slides Final Revised 05.03.2024 (pdf file)
     psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
     January 01, 2024 - .0000000000003148 https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105638 https://www.heart.org/-/media/Files

182. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
     January 01, 2024 - Spotlight Spotlight Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis 1 Source and Credits This presentation is based on the December 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Comment…

183. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
     January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…

184. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
     January 01, 2022 - Spotlight Spotlight Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis Source and Credits • This presentation is based on the November 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Narath Carlile MD MPH,…

185. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
     January 01, 2021 - Spotlight Spotlight Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough Source and Credits • This presentation is based on the April 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Verna Gibbs, MD o AHRQ W…

186. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
     January 01, 2020 - Spotlight Spotlight Some Patients Can’t Wait: Improving Timeliness of Emergency Department Care Source and Credits • This presentation is based on the 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm • Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD ○ Editor…

187. Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
     January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx Spotlight Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See…

188. Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
     January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx Spotlight When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Source and Credits • This presentation is based on the September 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psne…

189. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
     January 01, 2022 - Spotlight Spotlight Delayed Diagnosis of Mesenteric Ischemia Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc o AHRQ WebM&M…

190. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
     January 01, 2022 - Spotlight Spotlight False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy Source and Credits • This presentation is based on the September 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by:…

191. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
     January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx Spotlight A Missed Bowel Perforation – the Importance of Diagnostic Reasoning Source and Credits • This presentation is based on the September 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/web…

192. Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
     January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx Spotlight Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts  Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotl…

193. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
     January 01, 2022 - Spotlight Spotlight Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by K…

194. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
     January 01, 2021 - Spotlight Spotlight Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome Source and Credits • This presentation is based on the June 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Comm…

195. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37427/psn-pdf
     September 16, 2014 - Dennis Quaid files suit over drug mishap. October 21, 2009 Ornstein C. Los Angeles Times. … https://psnet.ahrq.gov/issue/dennis-quaid-files-suit-over-drug-mishap This article discusses one couple's … https://psnet.ahrq.gov/issue/dennis-quaid-files-suit-over-drug-mishap https://psnet.ahrq.gov/issue/heparin-overdose-three-infants-revisits-hospital-error-issues

196. Application of root cause analysis on malpractice claim files related to diagnostic failures. | PSNet
     psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic-failures
     March 01, 2011 - Study Application of root cause analysis on malpractice claim files related to diagnostic … Application of root cause analysis on malpractice claim files related to diagnostic failures. … Application of root cause analysis on malpractice claim files related to diagnostic failures.

197. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866731/psn-pdf
     September 18, 2024 - cognitive-autopsy-root-cause-analysis-medical-decision-making https://www.leapfroggroup.org/sites/default/files … /Files/Root%20Cause%20Analysis%20of%20Cases%20Involving%20Diagnosis%20A%20Handbook%20for%20Healthcare

198. Spotlight
     psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
     January 01, 2025 - Spotlight Spotlight Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations  1 Source and Credits This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Samantha Brown…

199. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/861882/psn-pdf
     January 31, 2024 - www.ahrq.gov/teamstepps-program/index.html https://psnet.ahrq.gov//#8 https://grants.nih.gov/grants/guide/pa-files … www.ecri.org/press/ecri-institute-diagnostic-tests-medication-p… https://grants.nih.gov/grants/guide/pa-files … /PA-23-291.html https://grants.nih.gov/grants/guide/pa-files/PA-23-290.html https://grants.nih.gov/grants … /guide/pa-files/PA-23-290.html https://grants.nih.gov/grants/guide/pa-files/PA-23-115.html https://grants.nih.gov … /grants/guide/pa-files/PA-23-115.html https://grants.nih.gov/grants/guide/pa-files/PA-21-267.html http

200. Spotlight (pdf file)
     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, …