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  1. psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx Spotlight A Missed Bowel Perforation – the Importance of Diagnostic Reasoning Source and Credits • This presentation is based on the September 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/web…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49564/psn-pdf
    July 01, 2008 - Dependence vs. Pain July 1, 2008 Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dependence-vs-pain Case Objectives Define opioid dependence and opioid withdrawal syndrome. Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid Withdra…
  3. 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-…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836794/psn-pdf
    March 31, 2022 - A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. March 31, 2022 Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-c…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72614/psn-pdf
    March 01, 2021 - Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes Originally published on December 22, 2020 Last updated on December 23, 2020 https://psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads- improved-outcomes Summary Multidisciplinary tea…
  6. psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
    October 01, 2016 - In Conversation With… Richard Platt, MD, MSc October 1, 2016  Also Read an Essay Citation Text: In Conversation With… Richard Platt, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33861/psn-pdf
    July 01, 2018 - In Conversation With… Gordon Schiff, MD July 1, 2018 In Conversation With… Gordon Schiff, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-gordon-schiff-md Editor's note: Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research and Practice, Associate Pr…
  8. psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
    July 01, 2017 - SPOTLIGHT CASE “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event Citation Text: Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
  9. psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
    March 27, 2024 - Annual Perspective Ensuring Patient and Workforce Safety Culture in Healthcare John Murray, Joann Sorra, Bryan Gale, Sarah Mossburg | March 27, 2024  View more articles from the same authors. Citation Text: Murray J, Sorra J, Gale B, et al. Ensuring Patient…
  10. psnet.ahrq.gov/web-mm/pill-organizing-plight
    June 19, 2018 - SPOTLIGHT CASE A Pill Organizing Plight Citation Text: McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTe…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72911/psn-pdf
    March 15, 2021 - The Impact of Communication on Medication Errors March 15, 2021 Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors The Case   A 93-year-old man with a history of chronic systolic heart failure…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867850/psn-pdf
    February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/persp…
  13. psnet.ahrq.gov/web-mm/deadly-duo
    April 28, 2021 - The Deadly Duo Citation Text: Maldonado JR. The Deadly Duo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  14. psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
    April 01, 2006 - SPOTLIGHT CASE Antiseizure Medication Disorder Citation Text: Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX En…
  15. psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
    May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room. Citation Text: Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49768/psn-pdf
    September 01, 2016 - A Pill Organizing Plight September 1, 2016 McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/pill-organizing-plight Case Objectives Identify patients at high risk for adverse drug events. List drugs that are considered inappropriate in older patients. …
  17. psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
    August 14, 2024 - SPOTLIGHT CASE Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. Citation Text: Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…
  18. psnet.ahrq.gov/web-mm/lot-pain-medications
    September 23, 2020 - SPOTLIGHT CASE A Lot of Pain (Medications) Citation Text: Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…
  19. 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…
  20. psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
    September 18, 2024 - SPOTLIGHT CASE Diagnostic Delay in the Emergency Department Citation Text: Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format:…

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