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psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
October 01, 2011 - SPOTLIGHT CASE
Abdominal Aortic Aneurysm Screening
Citation Text:
Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
November 01, 2012 - Defensive Medicine: "Glowing" with Pain
Citation Text:
Sethi MK. Defensive Medicine: "Glowing" with Pain. 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/node/49848/psn-pdf
January 01, 2019 - Inadequate Preanesthetic Evaluation, Airway Trouble
November 1, 2018
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
The Case
Case #1:
A 34-year-old woman was scheduled for a hysteroscopy under g…
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psnet.ahrq.gov/web-mm/after-visit-confusion
August 21, 2007 - After-Visit Confusion
Citation Text:
Ventres W. After-Visit Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
December 01, 2014 - PowerPoint Presentation
Spotlight
A Stroke of Error
This presentation is based on the December 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Kevin M. Barrett, MD, MSc, Consultant, Associate Professor of Neurology, Director, Neurohospitalist F…
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psnet.ahrq.gov/node/49524/psn-pdf
November 01, 2006 - Secured But Not Always Safe
November 1, 2006
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/secured-not-always-safe
The Case
An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative
osteoarthritis. She received spinal …
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psnet.ahrq.gov/node/73905/psn-pdf
October 06, 2021 - Health Equity and Maternal Health
October 6, 2021
Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/health-equity-and-maternal-health
Redefining Maternal Safety
Maternal safety refers to the safety of a person during pregnancy, childb…
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. 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/too-tight-control
March 20, 2013 - SPOTLIGHT CASE
Too Tight Control
Citation Text:
Rubin HR, Fajtova VT. Too Tight Control. 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/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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psnet.ahrq.gov/node/33801/psn-pdf
February 01, 2016 - In Conversation With…Christine A. Sinsky, MD
February 1, 2016
In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
Editor's note: Christine A. Sinsky, MD, is the Vice President for Professional Satisfaction at the American
Me…
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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/49819/psn-pdf
February 01, 2018 - Signout Fallout
February 1, 2018
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/signout-fallout
Case Objectives
Understand the role of communication failures in medical errors and preventable adverse events.
Review the evidence in support of handoff improvement pr…
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psnet.ahrq.gov/node/60745/psn-pdf
October 01, 2020 - Multiple High-Risk Events Involving Workflow for Wasting
of Medications Used by Anesthesia
July 29, 2020
Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications
Used by Anesthesia. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-high-risk-events-involvi…
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psnet.ahrq.gov/node/49549/psn-pdf
December 06, 2007 - Elopement
December 1, 2007
Gerardi D. Elopement. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/elopement
Case Objectives
Define elopement and differentiate it from wandering and leaving against medical advice.
Identify leading contributors to elopement events.
Describe strategies for preventing elopement…
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psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH
November 1, 2010
In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - SPOTLIGHT CASE
The ECG Is Not Normal
Citation Text:
Zuger A. The ECG Is Not Normal. 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/right-left-neither
November 16, 2022 - SPOTLIGHT CASE
Right? Left? Neither!
Citation Text:
Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
March 01, 2019 - In Conversation With… Susan Haas, MD, MSc
March 1, 2019
Also Read an Essay
Citation Text:
In Conversation With… Susan Haas, MD, MSc. 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/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - SPOTLIGHT CASE
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
Citation Text:
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…