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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - SPOTLIGHT CASE
Dangerous Shift
Citation Text:
Patterson ES. Dangerous Shift. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - SPOTLIGHT CASE
Signout Fallout
Citation Text:
Starmer AJ, Landrigan CP. Signout Fallout. 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/antibiotics-urisinusitis-simple-decision-gone-bad
January 01, 2014 - SPOTLIGHT CASE
Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad
Citation Text:
Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
June 01, 2015 - SPOTLIGHT CASE
Empiric Steroids: the Good, the Bad, and the Ugly
Citation Text:
Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015437-waters-final-report-2008.pdf
January 01, 2008 - Technology Exchange for Cancer Health Network (Tech-Net)
Grant Final Report
Grant ID: 5UC1HS015437
Technology Exchange for Cancer Health
Network (Tech-Net)
Inclusive Dates: 10/01/04 – 09/30/08
Principal Investigator:
Teresa Waters, PhD
Team Members:
Furhan Yunus, MD
Mindy Me…
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psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
July 17, 2024 - SPOTLIGHT CASE
Tough Call: Addressing Errors From Previous Providers
Citation Text:
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/851870/psn-pdf
July 31, 2023 - In Conversation with... Regina Hoffman about Building
Capacity for Patient Safety
July 31, 2023
In Conversation with.. Regina Hoffman about Building Capacity for Patient Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
Editor’s no…
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
March 24, 2025 - In Conversation with…Albert Wu, MD, MPH
May 1, 2011
Citation Text:
In Conversation with…Albert Wu, MD, MPH. 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/web-mm/blind-spot
July 30, 2020 - Blind Spot
Citation Text:
Lee LA. Blind Spot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - SPOTLIGHT CASE
The Missing Abscess: Radiology Reads in the Digital Era
Citation Text:
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?
Citation Text:
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
C…
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - SPOTLIGHT CASE
A Weighty Mistake
Citation Text:
Bokser SJ. A Weighty Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
November 16, 2022 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.
Citation Text:
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.. PSNet [inter…
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking
January 26, 2022
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
Disclosure of Relevant Financial Relationships: As a provider ac…
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - SPOTLIGHT CASE
Moving Pains
Citation Text:
Schell H, Wachter R. Moving Pains. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
August 04, 2021 - Transitions in Adolescent Medicine
Citation Text:
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49870/psn-pdf
August 10, 2019 - Anemia and Delayed Colon Cancer Diagnosis
August 10, 2019
Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
Case Objectives
Describe the initial evaluation for iron deficiency anemia in elderly adults…
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psnet.ahrq.gov/web-mm/weighing-surgical-safety
August 04, 2021 - SPOTLIGHT CASE
Weighing In on Surgical Safety
Citation Text:
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/volume-too-low-and-out
July 01, 2017 - SPOTLIGHT CASE
Volume Too Low: In and Out
Citation Text:
Miller MR. Volume Too Low: In and Out . 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/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - SPOTLIGHT CASE
Out of Sight, Out of Mind: Out-of-Office Test Result Management
Citation Text:
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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