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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - SPOTLIGHT CASE
Falling Through the Crack (in the Bedrails)
Citation Text:
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - Critical Echocardiogram Result Lost to Follow-up
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Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions
Lindsay E. Nicolle, MD | November 1, 2008
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Nicolle LE. Health Care–Acquired Urinary Tract Infection: The Pr…
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psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement
Carole Stockmeier, Sarah Mossburg, Lee Merton | September 24, 2024
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psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
November 15, 2023 - Hospital at Home℠ Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients.
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April 7, 2021
Innovation…
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psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - SPOTLIGHT CASE
Adolescent Diabetes: A Routine Visit?
Citation Text:
Slap GB. Adolescent Diabetes: A Routine Visit?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/dependence-vs-pain
October 30, 2019 - SPOTLIGHT CASE
Dependence vs. Pain
Citation Text:
Gordon AJ. Dependence vs. Pain . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - SPOTLIGHT CASE
Diagnosing HIV-It Doesn't Take a Brain Surgeon
Citation Text:
Chou R. Diagnosing HIV-It Doesn't Take a Brain Surgeon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/84413/psn-pdf
February 23, 2022 - A Loss of Trust and a Missed Diagnosis
February 23, 2022
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counci…
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psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH
November 1, 2008
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Citation Text:
In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 200…
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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…
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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…
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - Miscommunication During the Interhospital Transport of a Critically Ill Child
Citation Text:
Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human …
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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.
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psnet.ahrq.gov/node/853774/psn-pdf
September 27, 2023 - Delayed Evaluation of Abdominal Pain in an Elderly
Patient.
September 27, 2023
Klimkiv L, Utter GH, Barnes DK. Delayed Evaluation of Abdominal Pain in an Elderly Patient. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
The Case
An 85-year-old woman presente…
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psnet.ahrq.gov/perspective/what-makes-good-checklist
October 01, 2010 - What Makes a Good Checklist
Anne Collins McLaughlin, PhD | October 1, 2010
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McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/node/837913/psn-pdf
August 31, 2022 - Miscommunication During the Interhospital Transport of a
Critically Ill Child
August 31, 2022
Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-c…
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD
October 1, 2010
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Citation Text:
In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010.In Conversation with...Peter J. Pronovost, MD, PhD. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
February 26, 2020 - Delayed Evaluation of Abdominal Pain in an Elderly Patient.
Citation Text:
Klimkiv L, Utter GH, Barnes DK. Delayed Evaluation of Abdominal Pain in an Elderly Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia
Citation Text:
Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…