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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - SPOTLIGHT CASE
Spotlight: Mistaken Attribution, Diagnostic Misstep
Citation Text:
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. 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/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
November 15, 2023 - Hospital at Home℠ Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients.
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April 7, 2021
Innovation…
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psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
February 26, 2025 - In Conversation With… Sigall K. Bell, MD
September 1, 2018
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In Conversation With… Sigall K. Bell, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
June 01, 2011 - In Conversation with… Edward Tenner, PhD
June 1, 2011
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In Conversation with… Edward Tenner, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/33866/psn-pdf
September 01, 2018 - In Conversation With… Sigall K. Bell, MD
September 1, 2018
In Conversation With… Sigall K. Bell, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
Editor's note: Dr. Bell is Director of Patient Safety and Discovery at OpenNotes, Beth Israel Deaconess
Medical Center and As…
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - The Impact of Communication on Medication Errors
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Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - A Tale of Two Falls
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Jackson V, Satake A. A Tale of Two Falls. 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/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 2024 - SPOTLIGHT CASE
Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head
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Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
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psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP
November 1, 2005
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In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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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?
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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.
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psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - Do Not Miss Sepsis Needles in Viral Haystacks!
March 27, 2024
Hamline M, Shaikh U. Do Not Miss Sepsis Needles in Viral Haystacks!. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accredit…
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only
Spotlight
Delay in Appropriate Diagnosis and
Treatment Leading to Death from
Pulmonary Embolism
Source and Credits
• This presentation is based on the February 2021 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - SPOTLIGHT CASE
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
Citation Text:
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health
Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for
Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - The Safety of Medical Devices
Christopher Nemeth, PhD | June 1, 2011
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Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…
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psnet.ahrq.gov/node/843234/psn-pdf
January 01, 2013 - Overdose of Gabapentin and Oxycodone in a Patient with
End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts.
February 1, 2023
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with
End-Stage Renal Disease: A Case for Appropriate Interruptive D…
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psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - SPOTLIGHT CASE
Do Not Miss Sepsis Needles in Viral Haystacks!
Citation Text:
Hamline M, Shaikh U. Do Not Miss Sepsis Needles in Viral Haystacks!. 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/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - A Postpartum Woman with an Erroneous SARS-CoV-2 Test
Citation Text:
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/perspective/conversation-cindy-brach
December 27, 2019 - In Conversation With... Cindy Brach
December 27, 2019
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In Conversation With.. Cindy Brach. PSNet [internet]. 2019.In Conversation With... Cindy Brach. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience
William S. Krimsky, MD | November 1, 2005
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Citation Text:
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [inter…