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psnet.ahrq.gov/periodic-issue/periodic-issue-420
November 29, 2023 - December 13, 2023 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, repor…
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psnet.ahrq.gov/periodic-issue/periodic-issue-425
February 28, 2024 - January 31, 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, report…
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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/web-mm/discharging-our-responsibility
January 16, 2019 - Discharging Our Responsibility
Citation Text:
Fonarow GC. Discharging Our Responsibility. 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/web-mm/eptifibatide-epilogue
March 04, 2011 - Eptifibatide Epilogue
Citation Text:
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency
Citation Text:
Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…
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psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
February 23, 2022 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement
Citation Text:
Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - SPOTLIGHT CASE
The Other Side
Citation Text:
Vincent CA. The Other Side. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - SPOTLIGHT CASE
Watch the Warfarin!
Citation Text:
Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - SPOTLIGHT CASE
Crossing the Line
Citation Text:
Feldman JP, Gould MK. Crossing the Line. 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/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/web-mm/new-oral-anticoagulants
July 01, 2011 - SPOTLIGHT CASE
New Oral Anticoagulants
Citation Text:
Fang MC. New Oral Anticoagulants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - Continuity Errors in Resident Clinic
Citation Text:
Warm EJ. Continuity Errors in Resident Clinic. 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/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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Format:
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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.
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
Citation Text:
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
February 26, 2025 - In Conversation with...Albert Wu, MD, MPH
July 1, 2008
Citation Text:
In Conversation with..Albert Wu, MD, MPH. PSNet [internet]. 2008.In Conversation with...Albert Wu, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…
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psnet.ahrq.gov/node/33635/psn-pdf
July 01, 2006 - In Conversation with...Allan Frankel, MD
July 1, 2006
In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this
kind of work.
Dr. Allan …
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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - Spotlight
Missed Opportunities for Suicide
Risk Assessment
Source and Credits
• This presentation is based on the November 2019 AHRQ WebM&M
Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Glen Xiong, MD & Debra Kahn, MD
○ Editors in Chief, AHRQ We…
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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…