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psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
February 26, 2025 - In Conversation With... James P. Bagian, MD, PE
December 1, 2016
Citation Text:
In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016.In Conversation With... James P. Bagian, MD, PE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research a…
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
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psnet.ahrq.gov/web-mm/breakage-picc-line
June 21, 2023 - SPOTLIGHT CASE
Breakage of a PICC Line
Citation Text:
Dimov V. Breakage of a PICC Line. 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 …
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psnet.ahrq.gov/web-mm/check-twice-transport-once
March 15, 2023 - Check Twice, Transport Once
Citation Text:
DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - Communication Failure—Who's in Charge?
Citation Text:
Fackler J, Schwartz JM. Communication Failure—Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndN…
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psnet.ahrq.gov/perspective/conversation-christine-cassel-md
February 26, 2025 - In Conversation With… Christine Cassel, MD
June 1, 2015
Citation Text:
In Conversation With… Christine Cassel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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For…
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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:
Google Scholar Bi…
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psnet.ahrq.gov/node/49508/psn-pdf
January 01, 2007 - Language Barrier
April 1, 2006
Flores G. Language Barrier. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/language-barrier
The Case
A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish-
speaking parents when they noted that their daughter had generalized we…
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/web-mm/result-stopped-here
December 01, 2006 - The Result Stopped Here
Citation Text:
Astion ML. The Result Stopped Here. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - From Pain Relief to Risk: A Case of Suspected Opioid
Overdose in a Pediatric Patient
February 26, 2025
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a
Pediatric Patient. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overd…
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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/node/33875/psn-pdf
March 01, 2019 - In Conversation With… Susan Haas, MD, MSc
March 1, 2019
In Conversation With… Susan Haas, MD, MSc. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
Editor's note: Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs'
work focused on health…
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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/49672/psn-pdf
January 01, 2013 - The Lung Nodule That Refused To Grow
December 1, 2012
Balekian AA, Gould MK. The Lung Nodule That Refused To Grow. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/lung-nodule-refused-grow
Case Objectives
Define a solitary pulmonary nodule.
Identify the different initial first steps of management.
Identify …
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psnet.ahrq.gov/node/49501/psn-pdf
February 03, 2006 - Lost in Transition
February 1, 2006
Beach C. Lost in Transition. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/lost-transition
Case Objectives
Provide an overview of transitions in continuously operating industries
Review cognitive error
Describe the complex dynamics of transitions in emergency care
Pro…
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psnet.ahrq.gov/node/49865/psn-pdf
June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy
June 1, 2019
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
The Case
A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
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psnet.ahrq.gov/node/49828/psn-pdf
May 01, 2018 - Out of Sight, Out of Mind: Out-of-Office Test Result
Management
May 1, 2018
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
Case Objectives
Recognize the general responsibilities of…
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psnet.ahrq.gov/node/33736/psn-pdf
September 01, 2012 - In Conversation With… Jack Needleman, PhD
September 1, 2012
In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management
at UCLA School of P…
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psnet.ahrq.gov/node/49543/psn-pdf
September 01, 2007 - Medication Reconciliation: Whose Job Is It?
September 1, 2007
Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
Case Objectives
Appreciate the prevalence and impact of medication discrepancies at times of transition in …