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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - SPOTLIGHT CASE
Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough
Citation Text:
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - The Impact of Communication on Medication Errors
Citation Text:
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/perspective/conversation-sigall-k-bell-md
February 26, 2025 - In Conversation With… Sigall K. Bell, MD
September 1, 2018
Citation Text:
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/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - Life-Threatening Infant Overdose of Sodium Chloride
Citation Text:
Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. 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/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - Artificial Intelligence and Diagnostic Errors
January 31, 2020
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Hea…
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - In Conversation With... David Gruen, MD
January 31, 2020
Also Read the Essay
Citation Text:
In Conversation With.. David Gruen, MD. PSNet [internet]. 2020.In Conversation With... David Gruen, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research an…
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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program?
Ian Scott, MBBS, MHA, MEd | March 1, 2015
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety …
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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/node/74149/psn-pdf
January 07, 2022 - Multiple Missed Opportunities for Suicide Risk
Assessment in Emergency and Primary Care Settings
January 7, 2022
Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and
Primary Care Settings. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/multiple-missed-opportu…
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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/perspective/safety-medical-devices
June 01, 2011 - The Safety of Medical Devices
Christopher Nemeth, PhD | June 1, 2011
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View more articles from the same authors.
Citation Text:
Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…
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psnet.ahrq.gov/node/841467/psn-pdf
December 14, 2022 - A framework for assessing reasoning about controversial
end-of-life clinical decisions.
December 14, 2022
Fedyk M, Fairman N, Romano PS, et al. A framework for assessing reasoning about controversial end-of-
life clinical decisions. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/framework-assessing-reasonin…
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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/60611/psn-pdf
June 24, 2020 - Direct Oral Anticoagulants are High-Risk Medications with
Potentially Complex Dosing
June 24, 2020
Giannini J, Wong M, Dager W, et al. Direct Oral Anticoagulants are High-Risk Medications with Potentially
Complex Dosing. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk…
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psnet.ahrq.gov/node/865655/psn-pdf
April 24, 2024 - Under Pressure: Delayed Diagnosis of Compartment
Syndrome after Lower Leg Fracture.
April 24, 2024
Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment
Syndrome after Lower Leg Fracture. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-comp…
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psnet.ahrq.gov/node/60066/psn-pdf
March 25, 2020 - Some Patients Can't Wait: Improving Timeliness of
Emergency Department Care
March 25, 2020
Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
D…
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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/perspective/conversation-withdonald-m-berwick-md-mpp
November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP
November 1, 2005
Also Read an Essay
Citation Text:
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/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/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
May 26, 2021 - Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings
Citation Text:
Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…