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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60542/psn-pdf
    May 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride May 27, 2020 Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride The Case  An infant with trisomy 21 underwent repair of a…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843051/psn-pdf
    February 01, 2023 - Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. February 1, 2023 Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-…

  3. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
    January 01, 2022 - Spotlight Spotlight Intraosseous Line Extravasation in a Pediatric Trauma Patient Source and Credits • This presentation is based on the April 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: David Barnes, MD and Joseph Yoon, MD o…

  4. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-447
    July 10, 2024 - July 10, 2024 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, …

  5. In Conversation with...Atul Gawande, MD, MA, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
    September 01, 2007 - In Conversation with...Atul Gawande, MD, MA, MPH September 1, 2007  Also Read an Essay Citation Text: In Conversation with..Atul Gawande, MD, MA, MPH. PSNet [internet]. 2007.In Conversation with...Atul Gawande, MD, MA, MPH. PSNet [internet]. Rockville (MD): Agency…

  6. Life-Threatening Infant Overdose of Sodium Chloride | PSNet

    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. Copy Citation Form…

  7. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case | PSNet

    psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
    October 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case Citation Text: Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US …

  8. In Conversation With... David Gruen, MD | PSNet

    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…

  9. Artificial Intelligence and Diagnostic Errors | PSNet

    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…

  10. WebM&M: Case Studies | PSNet

    psnet.ahrq.gov/webmm-case-studies
    March 25, 2025 - WebM&M: Case Studies WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…

  11. Complications of ECMO During Transport | PSNet

    psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
    January 27, 2021 - Complications of ECMO During Transport Citation Text: Broman M. Complications of ECMO During Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73202/psn-pdf
    April 28, 2021 - A Postpartum Woman with an Erroneous SARS-CoV-2 Test April 28, 2021 Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test The Case A full-term pregnant patient was admitted in March 2…

  13. Health Care Data Science for Quality Improvement and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
    October 01, 2016 - Health Care Data Science for Quality Improvement and Patient Safety Alvin Rajkomar, MD | October 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Rajkomar A. Health Care Data Science for Quality Improvement and Patient S…

  14. WebM&M Cases & Commentaries | PSNet

    psnet.ahrq.gov/Webmm
    May 01, 2021 - WebM&M Cases & Commentaries WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by…

  15. Webmm

    psnet.ahrq.gov/webmm
    May 01, 2021 - WebM&M Cases & Commentaries WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by…

  16. The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance | PSNet

    psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
    April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance Lance L. Roberts, MS; Marcia M. Ward, PhD; Thomas C. Evans, MD | April 1, 2010  Also Read a Conversation View more articles from the same authors. …

  17. Premature Closure: Was It Just Syncope? | PSNet

    psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
    February 10, 2021 - SPOTLIGHT CASE Premature Closure: Was It Just Syncope? Citation Text: 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. Copy Citation Format: …

  18. A Postpartum Woman with an Erroneous SARS-CoV-2 Test | PSNet

    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. Copy Citation Forma…

  19. Rediscovering the Power of the Surgical M&M Conference: The M M Matrix | PSNet

    psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
    September 01, 2007 - Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix Leo A. Gordon, MD | September 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The…

  20. Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only (pdf file)

    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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