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psnet.ahrq.gov/node/33754/psn-pdf
September 01, 2013 - In Conversation With… Sidney Dekker, MA, MSc, PhD
September 1, 2013
In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
Editor's note: Sidney Dekker is Professor and Director of the Safety Science Innovation Lab at Grif…
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psnet.ahrq.gov/node/49642/psn-pdf
December 01, 2011 - Order Interrupted by Text: Multitasking Mishap
December 1, 2011
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
Case Objectives
State the prevalence of mobile devices among clinicians and their common health…
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - Coming Undone: Failure of Closure Device
Citation Text:
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/842923/psn-pdf
February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric
Patient Complicating Cardiac Surgery and Bedside Chest
Closure.
February 1, 2023
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient
Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …
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psnet.ahrq.gov/continuing-education
February 26, 2025 - Continuing Education
What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…
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psnet.ahrq.gov/node/33723/psn-pdf
December 01, 2011 - Implementing a Fall Prevention Program
December 1, 2011
Healey F. Implementing a Fall Prevention Program. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/implementing-fall-prevention-program
Perspective
Throughout the developed world, most hospital beds are occupied by older people, many of whom have
b…
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psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Transfer Troubles
June 1, 2012
Hains IM. Transfer Troubles. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfer-troubles
Case Objectives
Recognize that transfer of patients between hospitals is common.
Understand the frequency of errors and adverse events in the transfer of patients between hospitals.
…
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psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - The Wrong Shot: Error Disclosure
June 1, 2004
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
Case Objectives
Describe the rationale for disclosing harmful errors to patients.
Describe the specific information that patie…
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psnet.ahrq.gov/node/49498/psn-pdf
January 01, 2006 - An Ounce of Prevention
January 1, 2006
Kucher N. An Ounce of Prevention. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/ounce-prevention
Case Objectives
Assess risk for venous thromboembolism (VTE) in hospitalized patients
List recommended strategies for VTE prevention for various risk groups
Identify pat…
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psnet.ahrq.gov/web-mm/premature-extubation
May 25, 2011 - Premature Extubation
Citation Text:
Sagana R, Hyzy RC. Premature Extubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
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psnet.ahrq.gov/node/33814/psn-pdf
September 01, 2016 - In Conversation With… Reed V. Tuckson, MD
September 1, 2016
In Conversation With… Reed V. Tuckson, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md
Editor's note: Dr. Tuckson is Managing Director of Tuckson Health Connections, LLC, and President of
the American Telemed…
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psnet.ahrq.gov/node/33822/psn-pdf
January 01, 2017 - In Conversation With… Paul H. O'Neill, MPA
January 1, 2017
In Conversation With… Paul H. O'Neill, MPA. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
Editor's note: Mr. O'Neill served as the United States Secretary of the Treasury under President George
W. Bush and, prio…
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - No News May Not Be Good News
August 1, 2012
Moore CR. No News May Not Be Good News. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
Case Objectives
Describe the frequency with which ambulatory test results are not followed up by providers.
Appreciate that inadequate follow-up of…
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psnet.ahrq.gov/node/853773/psn-pdf
September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side.
September 27, 2023
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
The Case
A first-year orthopedic surgery resident was consulted…
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psnet.ahrq.gov/node/60857/psn-pdf
August 26, 2020 - Nothing Called Small Surgery
August 26, 2020
Manske C. Nothing Called Small Surgery. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/nothing-called-small-surgery
The Case
A 56-year-old female presented to surgical clinic with pain and swelling in left great toe associated with
progressive deformity of the …
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
January 01, 2024 - Spotlight
Spotlight
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
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: Garth Utter, MD, MSc, FACS…
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psnet.ahrq.gov/web-mm/result-stopped-here
December 01, 2006 - The Result Stopped Here
Citation Text:
Astion ML. The Result Stopped Here. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/autopsy-revelation
December 01, 2007 - Autopsy Revelation
Citation Text:
Shojania KG. Autopsy Revelation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/web-mm/undetected-foreign-object
April 24, 2018 - Undetected Foreign Object
Citation Text:
Cima RR. Undetected Foreign Object. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - Good Catch in the Operating Room
Citation Text:
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote …