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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - The Consequences of Miscommunication Regarding a
Possible Artifact
June 30, 2021
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
Disclosure of Relevant Financial Relationships…
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psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue
Citation Text:
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Cit…
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psnet.ahrq.gov/node/49588/psn-pdf
August 01, 2009 - Nurse Staffing Ratios: The Crucible of Money, Policy,
Research, and Patient Care
August 1, 2009
Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
Case…
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psnet.ahrq.gov/node/33678/psn-pdf
January 01, 2009 - In Conversation with…Thomas H. Gallagher, MD
January 1, 2009
In Conversation with…Thomas H. Gallagher, MD. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md
Editor's note: Thomas H. Gallagher, MD, is Associate Professor in the Department of Medicine and the
Departme…
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psnet.ahrq.gov/node/49705/psn-pdf
January 01, 2020 - A "Reflexive" Diagnosis in Primary Care
April 1, 2014
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
Case Objectives
Appreciate that primary care doctors may be caring for an increasing number of patients wi…
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psnet.ahrq.gov/node/33885/psn-pdf
August 01, 2019 - In Conversation With… Susan Smith, MD
August 1, 2019
In Conversation With… Susan Smith, MD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-susan-smith-md
Editor's note: Dr. Smith, a family medicine physician, is chief faculty practices officer for UCSF Health.
Over the past 3–4 years, the …
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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/854848/psn-pdf
October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures
October 31, 2023
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
The Case
A 32-year-old man presented to the hospital with…
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psnet.ahrq.gov/node/33718/psn-pdf
October 01, 2011 - In Conversation With… Paul G. Shekelle, MD, MPH, PhD
October 1, 2011
In Conversation With… Paul G. Shekelle, MD, MPH, PhD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd
Editor's note: Dr. Shekelle is director of the Southern California Evidence-Based Practice Cen…
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psnet.ahrq.gov/node/49798/psn-pdf
July 01, 2017 - Pseudo-obstruction But a Real Perforation
July 1, 2017
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
Case Objectives
Recognize acute colonic pseudo-obstruction and implement a medical management plan.
Ide…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
January 01, 2019 - Spotlight
Spotlight
Mistaken Attribution, Diagnostic Misstep
*
Source and Credits
This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD
…
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psnet.ahrq.gov/web-mm/emergency-error
January 18, 2013 - SPOTLIGHT CASE
Emergency Error
Citation Text:
Symons NRA. Emergency Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
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psnet.ahrq.gov/node/73302/psn-pdf
May 26, 2021 - In Conversation With... Chris Cebollero, BS, CCEMT-P
May 26, 2021
In Conversation With.. Chris Cebollero, BS, CCEMT-P. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-chris-cebollero-bs-ccemt-p
Editor’s Note: Chris Cebollero, BS, CCEMT-P, is the President and CEO of Cebollero & Associates
C…
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psnet.ahrq.gov/toolkits
March 01, 2025 - Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Want to submit a Toolkit?
Has your organization deve…
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psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
January 31, 2024 - The Unhappy Patient Leaves Against Medical Advice.
Citation Text:
Nichols A. The Unhappy Patient Leaves Against Medical Advice.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
Copy Citation
Format:
Google Scholar …
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication
Breakdown.
August 30, 2023
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Spotlight
Spotlight
Prolonged DKA in Pregnancy: A Case of Communication
Breakdown
Source and Credits
• This presentation is based on the August 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarah Marshall, MD and Nina M. …
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psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
August 20, 2018 - Buprenorphine and the Medically Ill Patient
Citation Text:
McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX E…
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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - Advancing Patient Safety Through State Reporting
Systems
June 1, 2007
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
Perspective
Seven years ago, the Institute of Medicine (I…
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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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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…