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  1. 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…
  2. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
  3. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  4. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …
  5. 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. Copy Citation Format: Google Scholar BibTeX EndN…
  6. 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. Copy Citation For…
  7. 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. Copy Citation Format: Google Scholar Bi…
  8. Psn-Pdf (pdf file)

    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…
  9. 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…
  10. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
  11. Psn-Pdf (pdf file)

    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…
  12. 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…
  13. Psn-Pdf (pdf file)

    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…
  14. 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…
  15. Psn-Pdf (pdf file)

    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 …
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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 …

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