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  1. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. | PSNet

    psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
    September 27, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. Citation Text: Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depa…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851389/psn-pdf
    July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer Summary Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, a…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49759/psn-pdf
    May 01, 2016 - Falling Through the Crack (in the Bedrails) May 1, 2016 Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/falling-through-crack-bedrails Case Objectives Review the epidemiology of patient falls and associated injuries in the hospital set…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850361/psn-pdf
    June 14, 2023 - Critical Echocardiogram Result Lost to Follow-up June 14, 2023 Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow The Case A 63-year-old man with history of stroke, systolic heart failure, and ventric…

  5. In Conversation With… Mark Chassin, MD, MPP, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
    April 26, 2023 - In Conversation With… Mark Chassin, MD, MPP, MPH April 1, 2017  Citation Text: In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Cit…

  6. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
    January 01, 2022 - Spotlight Spotlight Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy Source and Credits • This presentation is based on the August 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 K…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33789/psn-pdf
    August 01, 2015 - In Conversation With… Robert M. Wachter, MD August 1, 2015 In Conversation With… Robert M. Wachter, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md Editor's note: Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF, where he also …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49597/psn-pdf
    February 01, 2010 - Adolescent Diabetes: A Routine Visit? February 1, 2010 Slap GB. Adolescent Diabetes: A Routine Visit? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit Case Objectives Appreciate the increasing prevalence of obesity and type 2 diabetes mellitus (T2DM) among adolescents in the…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49415/psn-pdf
    September 01, 2003 - Intubation Mishap September 1, 2003 Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/intubation-mishap Case Objectives To understand and apply a structured method of human factors case analysis To describe the key components of effective teamwork To understand the imp…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33804/psn-pdf
    March 03, 2016 - In Conversation With… Paul McGann, MD March 1, 2016 In Conversation With… Paul McGann, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-paul-mcgann-md Editor's note: Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for Medicare & Medicaid Services (CMS). He…

  11. 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…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49566/psn-pdf
    July 01, 2008 - What Was in Those Platelets? July 1, 2008 Yomtovian R. What Was in Those Platelets? . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/what-was-those-platelets The Case A 47-year-old woman was admitted to the hospital for complex spinal surgery. The surgery went well without complications, and postoperativel…

  13. 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, …

  14. 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…

  15. 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…

  16. 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…

  17. 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…

  18. Intubation Mishap | PSNet

    psnet.ahrq.gov/web-mm/intubation-mishap
    April 26, 2023 - SPOTLIGHT CASE Intubation Mishap Citation Text: Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

  19. A Loss of Trust and a Missed Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
    October 31, 2023 - SPOTLIGHT CASE A Loss of Trust and a Missed Diagnosis Citation Text: Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format:…

  20. Missed Opportunities for Suicide Risk Assessment | PSNet

    psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
    September 27, 2023 - SPOTLIGHT CASE Missed Opportunities for Suicide Risk Assessment Citation Text: Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation For…
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