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psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cybersecurity
March 27, 2024 - Staff may be busy, so they must have focused attention on not only business continuity but clinical continuity
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psnet.ahrq.gov/node/73899/psn-pdf
September 29, 2021 - Lost in Transitions of Care: Managing an Opioid-
Dependent Patient with Frequent Hospitalizations
September 29, 2021
Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent
Hospitalizations. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/lost-transitions-care…
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psnet.ahrq.gov/periodic-issue/periodic-issue-292
May 26, 2021 - May 19, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, a…
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psnet.ahrq.gov/node/33867/psn-pdf
October 01, 2018 - In Conversation With… Michael Cohen, RPh, MS, ScD
(hon)
October 1, 2018
In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
Editor's note: Dr. Cohen is President of the Institute for Safe Medication Practice…
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psnet.ahrq.gov/node/49843/psn-pdf
October 01, 2018 - Spotlight: Overdiagnosis and Delay: Challenges in Sepsis
Diagnosis
October 1, 2018
Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
Case Objectives
Realize the im…
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psnet.ahrq.gov/node/33833/psn-pdf
May 01, 2017 - In Conversation With… David Juurlink, MD, PhD
May 1, 2017
In Conversation With… David Juurlink, MD, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
Editor's note: Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of
Toronto, w…
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psnet.ahrq.gov/node/60856/psn-pdf
August 26, 2020 - Too Many Cooks in the Kitchen
August 26, 2020
Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for
Continuing Medical Education (ACCME), the Un…
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psnet.ahrq.gov/node/33863/psn-pdf
August 01, 2018 - In Conversation With… Matthew Weinger, MD
August 1, 2018
In Conversation With… Matthew Weinger, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
Editor's note: Dr. Weinger is Director of the Center for Research and Innovation in Systems Safety and
Professor of Anesthes…
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psnet.ahrq.gov/node/49792/psn-pdf
May 01, 2017 - Diagnostic Delay in the Emergency Department
May 1, 2017
Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
Case Objectives
Appreciate the importance of a broad differential diagnosis for acute abdominal pai…
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psnet.ahrq.gov/node/49591/psn-pdf
October 01, 2009 - Difficult Encounters: A CMO and CNO Respond
October 1, 2009
Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
Case Objectives
Appreciate the risk of disruptive behavior and understand institutional respons…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
November 13, 2024 - Delayed Diagnosis of Endocrinologic Emergencies
Citation Text:
Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google …
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near-
Miss Wrong Transfusion Event
January 29, 2020
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
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psnet.ahrq.gov/node/850450/psn-pdf
June 14, 2023 - The One That Got Away—Elopement of a Suicidal Patient
in the Emergency Department.
June 14, 2023
Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the
Emergency Department. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-…
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
January 01, 2024 - Spotlight
Spotlight
Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head
1
Source and Credits
This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Ryan Martin, MD, FCNS and …
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psnet.ahrq.gov/node/50613/psn-pdf
October 30, 2019 - In Conversation With… Neel Shah, MD, MPP
October 30, 2019
In Conversation With… Neel Shah, MD, MPP. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp
Editor's note: Dr. Shah, MD, MPP, is an Assistant Professor of Obstetrics, Gynecology and Reproductive
Biology at Harvard Medi…
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psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
December 02, 2020 - SPOTLIGHT CASE
The Lost Start Date: an Unknown Risk of E-prescribing
Citation Text:
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. 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/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - SPOTLIGHT CASE
Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy
Citation Text:
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…
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psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
February 26, 2025 - In Conversation With… Eric J. Topol, MD
September 1, 2015
Citation Text:
In Conversation With… Eric J. Topol, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Form…
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - SPOTLIGHT CASE
Multifactorial Medication Mishap
Citation Text:
Yang A. Multifactorial Medication Mishap. 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 EndNot…
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - SPOTLIGHT CASE
Suicidal Ideation in the Family Medicine Clinic
Citation Text:
Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
…