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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - Spotlight
Spotlight
A Case of Mistaken Capacity: Why a
Thorough Psychosocial History Can
Improve Care
Source and Credits
• This presentation is based on the March 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: Katrina Pasao, MD…
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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…
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - SPOTLIGHT CASE
Too Many Cooks in the Kitchen
Citation Text:
Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citation
Format:
Google Scholar BibTeX EndNote X…
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an
Order is Not Enough
April 28, 2021
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
Disclosure of Relev…
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care
Following Cesarean Delivery.
November 25, 2020
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean
Delivery. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesare…
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psnet.ahrq.gov/web-mm/what-was-those-platelets
August 28, 2024 - What Was in Those Platelets?
Citation Text:
Yomtovian R. What Was in Those Platelets? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
November 01, 2016 - SPOTLIGHT CASE
Dying in the Hospital With Advanced Dementia
Citation Text:
Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Ci…
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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…
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psnet.ahrq.gov/web-mm/ebola-are-we-ready
July 01, 2012 - Ebola: Are We Ready?
Citation Text:
Barsuk JH, Barnard C. Ebola: Are We Ready?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Spotlight
Spotlight
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
1
Source and Credits
This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Samantha Brown…
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psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
October 31, 2023 - SPOTLIGHT CASE
Robotic Surgery: Risks vs. Rewards
Citation Text:
Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Googl…
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psnet.ahrq.gov/node/867022/psn-pdf
October 30, 2024 - Delayed Symptomatic Subdural Hematoma Following an
Initially Normal CT Head
October 30, 2024
Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-h…
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Intraoperative Awareness during Rhinoplasty
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Christian Bohringer MBBS and Jaijeet Toor MD
AHRQ WebM&M Edit…
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psnet.ahrq.gov/node/867359/psn-pdf
December 18, 2024 - Importance of Following Safe Practices for Infant Feeding
and Handling Expressed Breast Milk
December 18, 2024
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling
Expressed Breast Milk. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/importance-following-saf…
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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…
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psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Intraosseous Line Extravasation in a
Pediatric Trauma Patient
Source and Credits
• This presentation is based on the April 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: David Barnes, MD and Joseph Yoon, MD
o…
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - Premature Closure: Was It Just Syncope?
November 25, 2020
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
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psnet.ahrq.gov/node/49537/psn-pdf
June 01, 2007 - Beeline to Spine
June 1, 2007
Smetana GW. Beeline to Spine. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/beeline-spine
Case Objectives
Understand the elements of preoperative medical evaluation.
Appreciate the limited role for preoperative laboratory testing.
Appreciate the importance of communication a…
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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 …
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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…